Claims Assessor
7 days ago
Job Location : Gauteng, Johannesburg
Deadline : April 05
Requirements:
- Matric / Grade 12
- Basic medical qualification an advantage (e.g. nursing or similar qualification)
- Computer Literacy (MS Word, Outlook and Excel)
- FAIS Fit and Proper including RE5
- At least 2 years medical aid or gap cover claims processing and assessing experience
- At least 1 year insurance experience
- Basic knowledge of the local health and medical schemes industry, as well as an awareness of demarcation and legislation governing the local health industry
Duties & Responsibilities:
- Receive new claims via email and accurately pre-capture them, including updating members' personal details, onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.
- Receive new Seamless claims via Secured sites, importing them into the system – including the updating of members' personal details – onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.
- Ensure claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed SLA's.
- Interact with customers telephonically or via email regarding outstanding information or claims documentation on the same day or within 24 hours of receiving or capturing the claim.
- Accurately capture the clinical details of a claim on the claims administration system (OWLS) on the same day or within 2 working days of receipt.
- Prioritise claims where outstanding documentation has been received, ensuring these documents are captured within 48 hours of receipt.
- Assess claims in accordance with practice guidelines, policy wording, and protocols.
- Finalize and forward claims to the quality assurance team for approval or rejection.
- Ensure prompt handling and feedback on claims.
- Respond to capture queries within 48 hours of receipt.
- Detect and act on potential fraudulent claims.
- Maintain a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, and colleagues.
- Provide support to the front-line team for inbound call overflows, query handling, complaints handling, and mailbox coordination when requested.
- Ensure the principles of Treating Customers Fairly (TCF) are delivered across all functions, with a specific focus on achieving TCF Outcome 6 (ensuring customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim, or make a complaint).
- Dealing with client and medical scheme queries as and when they arise within the stipulated timeframe.
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