Claims Specialist | TALENT POOL MMH251114-12

3 days ago

Sandton, South Africa Momentum Full time

Claims Specialist | TALENT POOL MMH Join to apply for the Claims Specialist role at Momentum. Role Purpose To lead the resolution of high-level and escalated queries, retain the current membership base, and take responsibility for the quality, timely delivery, and appropriateness of the team's recommendation. Requirements Matric Computer literate. Comprehensive knowledge of all aspects of medical aid assessing is essential. Working on the Oracle platform is an advantage. Knowledge of relevant legislation and industry regulations Knowledge of the claims assessment process (e.g., paper and EDI) Knowledge of the relevant scheme or product rules Knowledge of relevant operating systems and tools 3 - 5 years medical aid claims administration or related experience Exposure to the insurance industry (preferred) Duties and Responsibilities Process Review submitted claims to ensure accuracy and completeness, facilitating the determination of compensation. Accurately process incoming claims within the defined service level agreement. Evaluate and process claims and payments according to predetermined standards and rules. Identify and reject duplicate claims to prevent duplication of compensation. Coordinate or conduct investigations on complex claims, make informed decisions based on findings, and approve or reject claims accordingly. Assist clients and internal stakeholders with queries related to claims. Conduct quality control checks to minimize error rates in claim processing. Escalate queries requiring further investigation and provide timely feedback to clients. Generate reports and provide internal clients with updates on the status of claims. Provide clear reasons for rejecting claims based on investigations and contractual obligations. Client Offer authoritative expertise to clients and stakeholders regarding claims matters. Foster and maintain strong relationships with clients and internal and external stakeholders. Fulfill service level agreements with clients and stakeholders to effectively manage client expectations. Make recommendations for enhancing client service and ensuring fair treatment within the scope of responsibility. Actively participate in creating a culture that values relationships, encourages feedback, and delivers exceptional client service. People Develop and maintain productive and collaborative relationships with peers and stakeholders. Actively contribute to and support change initiatives within the organization. Continuously enhance professional expertise in terms of industry knowledge, legislation, and best practices. Contribute to continuous innovation by sharing and implementing new ideas. Take ownership of career development and drive personal growth. Finance Contribute to the financial planning process within the designated area. Identify opportunities to improve cost-effectiveness and operational efficiency. Manage financial and other resources under your control with diligence and responsibility. Provide input into risk identification processes and communicate recommendations in the appropriate forums. Seniority level Mid-Senior level Employment type Full-time Job function Finance and Sales #J-18808-Ljbffr

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