1. SSC/N2401 (Maintain employer accounts PC1. check systems to verify whether master records of employer accounts already exist 100 20 0 20 PC2. obtain required data/information from appropriate sources to set up, configure and update employer accounts 10 10 0 PC3. clarify any issues with the data/information with appropriate people 5 5 0 PC4. set up, configure and update employer accounts, following your organization’s procedures, guidelines and client-specific service level agreements (SLAs) 20 0 20 PC5. check configuration of employer accounts with peers and/or supervisor, as required 10 10 0 PC6. obtain confirmation from employers that account details held in their master records are correct 15 0 15 PC7. obtain advice and guidance from appropriate people, where required 5 5 0 PC8. comply with your organization’s policies, procedures, guidelines and SLAs when maintaining employer accounts 15 0 15 100 30 70 2. SSC/N2402 (Maintain member records for health insurance schemes) PC1. check systems to verify whether member records already exist 100 15 0 15 PC2. obtain required data/information from appropriate sources to set up, configure and update member records 10 10 0 PC3. clarify any issues with the data/information with appropriate people 5 5 0 PC4. verify eligibility of applicants to enroll in health insurance schemes and their level of benefits 15 0 15 PC5. set up, configure and update member records, following your organization’s procedures, guidelines and client-specific service level agreements (SLAs) 15 0 15 PC6. check configuration of member records with peers and/or supervisor, as required 5 5 0 PC7. obtain confirmation from members that details held in their records are correct 15 0 15 PC8. obtain advice and guidance from appropriate people, where required 5 5 0 PC9. comply with your organization’s policies, procedures, guidelines and 15 0 15 specific client-
5. SSC/N2409 (Coordinate health insurance claims on behalf of healthcare providers) PC1. obtain required data/information for health insurance claims from appropriate sources 100 10 5 5 PC2. validate the accuracy and completeness of data/information 5 0 5 PC3. verify eligibility of claims against policy documents 10 5 5 PC4. analyze explanation of benefits (EoB) documentation to determine amounts to be claimed 15 5 10 PC5. enter claims onto billing systems, following your organization’s procedures, guidelines and client-specific service level agreements (SLAs) 15 5 10 PC6. complete claim forms in line with health insurers’ requirements 15 5 10 PC7. respond to queries from patients, policyholders and health insurers in line with SLAs 5 0 5 PC8. monitor payments from health insurers and take action in case of delays in payment, in line with your organization’s procedures, guidelines and client specific service level agreements (SLAs) 5 0 5 PC9. apply payments to relevant claims in billing systems 10 5 5 PC10. obtain advice and guidance from appropriate people, where required 5 0 5 PC11. comply with your organization’s policies, procedures, guidelines and SLAs when coordinating health insurance claims 5 0 5 Total 100 30 70 6.SSC/N9001 (Manage your work to meet requirements) PC1. establish and agree your work requirements with appropriate people 6.25 0 6.25 PC2. keep your immediate work area clean and tidy 12.5 6.25 6.25 PC3. utilize your time effectively 12.5 6.25 6.25 PC4. use resources correctly and efficiently 18.75 6.25 12.5 PC5. treat confidential information correctly 6.25 0 6.25 PC6. work in line with your organization’s policies and procedures 12.5 0 12.5 PC7. work within the limits of your job role 6.25 0 6.25 PC8. obtain guidance from appropriate people, where necessary 6.25 0 6.25
health care provider records and contracts , process health insurance claims & coordinate health insurance claims on behalf of health care providers. the importance of verifying eligibility for health insurance schemes methods and tools to verify eligibility of applicants and the associated level of benefits procedures for obtaining signed contracts from healthcare providers what to do when contracts have not been returned different types of claims and how to deal with these methods and tools to verify eligibility of claims how to determine the amount of claims using explanation of benefits (EoB) documentation eligibility criteria for health insurance schemes and associated level of benefits basic legal and regulatory requirements governing contracts how to prepare healthcare provider contracts how to set up, configure and update healthcare provider records procedures and techniques used for confirming record/contract details with providers and implications for organization if this is not done quality orientation and attention to detail. The core & generic job skills to collecting and organising information, communication that an individual should have, will help him/her understand & manage assigned works in the context of the social environment of the customer. These tasks will require the individual to take responsibility of his/her own work and learning and full responsibility other’s work & learning. Individual at this job does not work under supervision, as needed at Level 3 & is responsible for his/her own learning. He/she is fully responsible for other’s work & learning (unlike not/partially as in level 4/5). He/she is also sometimes fully responsible for the output of the group. Therefore, this QP is justified to be pegged at Level 7. Summary of other evidence (if used): Validated by Industry council through various workshops and through training provider stake holders