Claims Specialist X 2

7 days ago

Cape Town, South Africa Health Solutions Full time

**Introduction**
- Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities**Disclaimer**
- As an applicant, please verify the legitimacy of this job advert on our company career page.**Role Purpose**
- To lead the resolution of high-level and escalated queries, enhance the service experience and take responsibility for the quality, timely delivery of escalated queries for all stakeholders.**Requirements**:

- Matric
- 3 - 5 years medical aid claims administration experience (essential)
- 2 - 3 years query management experience (essential)
- 2 - 3 years of client service experience (essential)
- Medical claims assessing experience (Essential)
- Exposure to the insurance industry (preferred)
- 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

**Duties & 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

**Competencies**
- Excellent verbal and written communication skills
- Client stakeholder commitment
- Work independently
- Collaboration

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