1. JOB TITLE: TECHNICAL SPECIALIST – Claims 1st Line Support
JOB OBJECTIVE
 Maintain the Masterfiles in line with the Rules of the Scheme.
 Ensure quality management and control on masterfiles.
 Conduct Annual Audits of Scheme Rules.
 Ensure that the new year’s Benefit and Rules are implemented and signed off
 Maintain and enhance business processes.
 Manage and co-ordinate the links between the various areas of the business (fromstaff to
Management) and IT (2nd Line Support, Healthcare Management and relevant 3rd Parties (Onecare,
MSO) and where necessary, interpret and suggest any changes or needs.
 Provide high quality operational and technicalsupport in order to assist Business Unit and MHG Admin
with new ideas for systemchanges and enhancements and professional analysis to all projects.
 Ensure that Business Unit systemusers are at all times adequately trained and up to date with the latest
systemreleases
 As part of project team, liaise with the Product Manager and Business Analyst in order to manage the
smooth integration of new business within the Metropolitan Health Group which includes system
integration and business processes

2. 1. OperationsandMaintenance
KEY FUNCTIONS:
 Receive, analyse and resolve Service Desk requests submitted by users.
 Submit Incidents on behalf of the business for those Service Desk requests that cannot be resolved on 1st line
level.
 Ensure that all required information is provided on the Incident logged, and provide additional information to
IT if and when required.
 Ensure that Service Desk requests, are timeously resolved
 Coordinate and manage maintenance requests between the Business Unit and IT.
 Ensure that MHG Systems accommodate all the processes taking into account:
 Legislative requirements (Communications fromCMS, BHF etc.)
 Business requirements (Loading of Claims Rules etc.)
 IT requirements
 3rd party requirements.
 Ensure that all the documentation exists and that sign-offis obtained on all systemreleases (SAS 70
requirements).
 In conjunction with the Scheme Manager, align business processes.
 Ensure that systemrequests accommodate all information and detail required in order for IT to affect the
request as timeously and correctly as possible.
 Analysis of systemrequests at alltimes in order to identify inefficient business process,training requirements
and systemenhancements.
 Continually review systems to ensure they remain efficient and effective.
 Ensure that the MHG Financial systems are fully integrated with the business processes and interface in an
effective manner.
 Ensure functional and accuracy of all 3rd party interfaces.
 Recommend developments on Business Processes with the view on maximising efficiency and minimising
administrative costs.

3.  Identify areas of systemenhancement where appropriate.
 Ensure that regular interaction and exchange of information is achieved between IT and the business.
 Compile proper system/test documentation and ensure the safe keeping thereof.
 Attend monthly Forum meetings for 1st and 2nd line support and ensure to communicate minutes back to the
business unit or alert Scheme Manager of any possible impact to the business unit processes
 TAR-rule Maintenance
 Liaise with MedicalAdvisors re the correct linkage of a tariff-discipline combination to a Rule for any new
tariffs
 Ensure tariff-discipline combinations are loaded
 Test claims for correctness
 Review changes viaAudit Trail (Scheme Manager)
OUTPUT
 Effective process in place, which are fully tested and signed off.
 Streamlined systemin place, which will accommodate all Schemes under Administration and adhere to the
approved SLA.
 Timeous integration of client information.
 Up to date status reports
SUCCESS MEASURE:
 Internal and External Clients satisfaction, which includes but are not limited to: members, business partners,
service providers and business units.
 Smooth functioning of all daily operations
TIME ALLOCATION:
40%

4. 2. Project Management
KEY FUNCTIONS:
Initiate or upon request, manage and co-ordinate specific business projects aimed at improving systems and
imparting knowledge, with the focus on contingency plans including but not limited to:
 Manage individual projects as and when they arise.
 Project Management including but not limited to:
 Feasibility study
 Project request
 Project definition report
 User specification
 Project Milestone
 Test plan
 Testing
 Implementation plan
 Training plan
 Maintenance plan
 Ensure deadlines are met within business and IT.
 Before rolling out project to live environment facilitate training if and where necessary.
 Ensure that projects are implemented with no or as little negative impact on the business as possible.
 Ensure efficient roll out with the view on maximising efficiency and minimising administrative costs during
project lifecycle.
 Ensure that all projects are completed professionally,with high quality and are on time
 Annual Changes:
 Ensure full Audit on current year’s Benefit and Rules.
 Obtain Rule & Benefit changes fromScheme Manager.
 Ensure that Rule & Benefit changes are interpreted correctly.
 Ensure that Benefit Comparison is done for current year and next year benefits.
 Determine if there is any systemdevelopment and inform 2nd line support via service centre.
 Load New Year Benefit and Rule changes.

5.  Ensure that new rules loaded get tested and audited.
 Ensure to get final sign off fromScheme Manager on New Year’s project.
 All test documents must be kept for audit purposes.
OUTPUT
 Projects are implemented on time with limited or no impact on the business.
 The Business is at alltimes up to date with the latest systemreleases and is fully trained.
 Up to date Training manuals.
SUCCESS MEASURE:
 Successful, on time implementation of projects where and when required.
 Business not submitting system requests as a result of inefficient system knowledge.
TIME ALLOCATION:
20%

6. 3. Trainingandtesting
KEY FUNCTIONS:
 Ensure that Business Unit and MHG Admin are aware of all systemfunctionally including but not
limited to:
 Facilitate training (individual or group) as new enhancements takes place.
 Document all enhancements and developments including the various training modules.
 Ensure that training department is aware of all enhancements and new developments.
 Identify training needs within the business on the current system. Subsequently
arranging or giving the necessary training required.
 Testing of all Service Desk Requests, enhancements and new developments including but not limited
to:
 Positive as well as negative testing.
 Documenting of all testing for Auditing purposes (as per SAS70 requirements).
 Ensure that all developments meet user requirements.
 Ensure that Service Desk Requests fix, enhancement or new development does not negatively
impact current MHG systems. (I.e. Business process is not negatively affected.)
OUTPUT:
 The business is at all times fully trained and utilising the systemoptimally.
 Updated and complete training manuals are available for training of new staffas well as
reference for existing staff.
 Comebacks of any Service Desk request fixes, enhancements or new developments, to
happen as little as possible
SUCCESS MEASURE:
 Business not submitting systemrequests as a result of efficient systemknowledge.
 Optimal usage of MHG System.
 Successful implementation of bug fixes,enhancements and new development.
TIME ALLOCATION:
10%

7. 4. Business Analyst
KEY FUNCTIONS:
 Identify inefficient business and or systemprocesses.
 Analyse and map business processes identified as inefficient.
 Proposing and ensure implementation of new or enhanced business and or system
processes.
 Analysing of Service Desk Requests, identifying systemimprovements and or
enhancements to increase productivity and decrease costs and ensure
implementation of changes
 Ensuring that systemchanges are at all times catering for ongoing business changes
and requirements.
 Ensuring that redundant systemprocesses are removed.
OUTPUT:
 Optimal usage of systemreducing costs and increasing productivity.
SUCCESS MEASURE:
 Fully optimal systemcatering for all business needs (existing and new business).
TIME ALLOCATION:
30%

8. NATURE OF LIAISON AND CONTACTS
PEOPLE/PARTIES/INSTITUTIONS/CLIENTS NATURE OF CONTACTS
EXTERNAL
 Medical Schemes under administration
 Existing and Prospective Clients
 Service Providers
 Medical Advisors
 Professional bodies
 Business Partners
INTERNAL
 MHG Admin Management
 MHG Admin Business Units
 MHRM Hospital Case Management
 MHG IT Management
 MHG IT Applications
 MHG IT Infrastructure
 MHG Support Forum for 1st and 2nd line
 Information exchange
 Data files
 Systemmapping
 Interface file queries
 Providing solutions to
operational problems.
 Providing feedback to
operational queries.
 Providing integration of
systemand business
processes
 Identifying possiblesystem
enhancements to all
business units.
 To attend monthly Forum
meetings and to provide
feedback to the business
units