Claims Assessor

2 days ago

Sandton, South Africa Momentum Metropolitan Holdings 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)
- FAIS Fit and Proper including RE5
- A minimum of 2 years medical or short-term health and accident insurance claims handling experience
- A minimum of 2 years client servicing experience
- A good knowledge of the local healthcare industry
Duties & Responsibilities
- 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 import 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 claim administration system on the same day or within 2 working days of receipt
- Prioritising 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 and colleagues
- Where requested, providing support to the front-line team for inbound call overflows, query handling, complaints handling and mailbox coordination
- 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 post-sale 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 claims 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 claims-related 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 decision-making capability
- Organised and focused
- Analytical skills with attention to detail
- Resilience and ability to work under pressure

Policy

We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.

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