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Quality Consultant: Claims Management
4 weeks ago
**Job Advert Summary**:
**Minimum Requirements**:
- A minimum of Grade 12
- A minimum of 6 years’ experience in medical scheme claims administration
- 5 years’ knowledge of the medical aid industry, regulations, RPL, ISO and other related legislation
- 1 year knowledge of coding systems (RPL, ICD)
- 1 year experience in Keyhealth and Profmed Scheme Rules
- 2 years’ MIP and MSO system knowledge
- Good communication, administration skills including record keeping and the ability to work under pressure
- Must be a strong team player
- Computer literacy (Basic Excel Skills)
- Quality orientated
- Attention to detail
- Proficient in MS Office
**Duties and Responsibilities**:
- Carry out spot checks on both paper and EDI claims processes by consultants daily.
- Reconcile member or provider claims received
- Evaluate and assess the quality of the consultants’ work using the Administration system, documented processes and published reports in order to identify and address problems or shortcomings within the group.
- Generate ad hoc reports on Jasper
- Quality control to ensure error rate is minimized
- Calculate individual error rates, compile and maintain an excel spreadsheet on a daily basis using information of individual error rates in order to send updated statistics to the Claims Coach
- Provide feedback to coaches on possible areas of growth per consultant
- Ensure accurate and timeous processing of medical claims received from Members and Service Providers when needed.
- Assisting with all ad hoc requests when required
- Behave in alignment with the PPSHA values.
- Analyse data (errors) to identify areas for improvement in the Administration system
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