Claims Assessor

3 weeks ago

Centurion, South Africa Private Health Administrators (Pty) Ltd Full time

Position Purpose: To ensure that claim lines that require manual intervention are released efficiently and timeously, as per agreed TAT by applying assessing and Scheme rules. Experience: A minimum of 2-3 years’ experience in a Managed Healthcare will be advantageous. Qualifications: Tertiary qualification in related field. KEY PERFORMANCE AREAS Conduct accurate and effective intervention/reconciliation of administration on all allocated claims Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement Continuously apply relevant rules Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims Rectify incorrect information on claims and elevate where required Reconcile claims where required and communicate outcome Ensure correct payments to vendor or member Meet delivery objectives through working with other team members within and linked to the department / project Resolve operational performance variations and problems and elevate unresolved issues to higher levels Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery KEY COMPETENCIES Knowledge Knowledge and application of dispensing of meds, surgical material & procedures Application of financial and risk assessment methodology Knowledge of scheme rules and contractual negotiations Application of clinical intervention principles Advise on best practice health risk solutions to relevant parties Knowledge and application of relevant legislation Knowledge and application of processes and procedure Skills Emails / HIP / Excel / Word Negotiation and Telephone Skills Communication Skills Business Writing Skills Relevant systems knowledge and application Ability to negotiate and influence Problem Solving Numerical Ability Customer Focus Attention to Accuracy and Detail Note: Company reserves the right to close the advert before specified closing date. PHA has its head office in Westville, KwaZulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits. #J-18808-Ljbffr

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