Quality Consultant: Claims Management

2 weeks ago


Centurion, Gauteng, South Africa PPS Recruitment Full time

Job Advert Summary:

Minimum Requirements:

  • A minimum of Grade 1
  • A minimum of 6 years' experience in medical scheme claims administration
  • 5 years' knowledge of the medical aid industry, regulations, RPL, ISO and other related legislation
  • 1 year knowledge of coding systems (RPL, ICD)
  • 1 year experience in Keyhealth and Profmed Scheme Rules
  • 2 years' MIP and MSO system knowledge
  • Good communication, administration skills including record keeping and the ability to work under pressure
  • Must be a strong team player
  • Computer literacy (Basic Excel Skills)
  • Quality orientated
  • Attention to detail
  • Proficient in MS Office

Duties and Responsibilities:

  • Carry out spot checks on both paper and EDI claims processes by consultants daily.
  • Reconcile member or provider claims received
  • Evaluate and assess the quality of the consultants' work using the Administration system, documented processes and published reports in order to identify and address problems or shortcomings within the group.
  • Generate ad hoc reports on Jasper
  • Quality control to ensure error rate is minimized
  • Calculate individual error rates, compile and maintain an excel spreadsheet on a daily basis using information of individual error rates in order to send updated statistics to the Claims Coach
  • Provide feedback to coaches on possible areas of growth per consultant
  • Ensure accurate and timeous processing of medical claims received from Members and Service Providers when needed.
  • Assisting with all ad hoc requests when required
  • Behave in alignment with the PPSHA values.
  • Analyse data (errors) to identify areas for improvement in the Administration system

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