Claims Assessor

2 weeks ago

Sandton, South Africa Guardrisk Full time

Introduction


Processing of medical expense shortfall (gap cover) claims in accordance with stipulated service levels and in terms and conditions of cover as defined in policy wording.


Role Purpose


Processing of medical expense shortfall (gap cover) claims in accordance with stipulated service levels and in terms and conditions of cover as defined in policy wording.


Requirements:

  • Matric
  • Basic medical qualification an advantage (e.g., nursing or similar qualification)
  • Computer Literacy (MS Word, Outlook, and Excel)
  • FAIS Fit and Proper including RE
  • At least 2 years medical or shortterm health and accident insurance claims handling experience
  • At least 2 years client servicing experience
  • A good knowledge of the local healthcare industry

Duties & Responsibilities

  • Ensuring that the principles and outcomes of TCF (Treating Customers Fairly) are practised and achieved in all duties performed and services provided to Admed customers
  • Ensuring the cradletograve coordination of all gap claims received electronically from contracted medical schemes with the objective of achieving an entirely seamless claims experience for mutual customers
  • Dealing with client and medical scheme queries as and when they arise within the stipulated timeframe
  • Ensuring that claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed SLA's
  • Ensuring the ongoing successful importing of claims data into the claim administration system
  • Ensuring that all registered claims are assessed and administered effectively and efficiently in terms of the relevant and prevailing legislation and policy wording
  • Accurately and completely capturing the clinical details of a claim on the claim administration system on the same day or within 2 working days of receipt
  • Prioritizing claims where outstanding documentation has been received ensuring that these documents are captured within 48 hours of receipt
  • Assessing claims in accordance with practice guidelines, policy wording and protocols
  • Finalisation and forwarding of claims to the quality assurance team for approval / rejection
  • Ensuring prompt handling and feedback on claims
  • Responding to capture queries received within 48 hours of receipt
  • Detecting and acting on potential fraudulent claims
  • Ensuring a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, Medical schemes and colleagues
  • Ensuring that the principles of TCF are delivered across every function performed, with a specific focus on the achievement of TCF Outcome 6 (Customers do not face unreasonable postsale barriers to change product, switch provider, submit a claim or make a complaint)
  • Where relevant, engaging with the Admed claims team and the respective medical schemes in respect of changing benefits and protocols, updating system rules and data file specifications
  • Liaising with the contracted medical schemes in respect of all the claim's integration matters, including challenges, changes, etc
  • Liaising with the Guardrisk IT Department and its appointed external developers in respect of system requirements, changes and problems
  • Monitoring of claimsrelated system communication with customers, to ensure that customers are always kept up to date during the claims process

Competencies

  • Results and solutions driven
  • Strong focus on client centricity and service excellence
  • Strong problem solving and decisionmaking capability
  • Organised and focused
  • Analytical skills with attention to detail
  • Resilience and ability to work under pressure
  • Adaptability and selfdiscipline
  • Effective communication skills and ability to professionally manager customers
  • Disciplined and reliable
  • A team player

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