Medical Scheme Claims Assessor X3
2 weeks ago
**Job Advert Summary**:
Rand Water is looking for a Medical Scheme Claims Assessors to manage daily operational requirements of the Rand Water Medical Scheme for claims assessing (auditing) and monitoring requirements for clinical IT administration system enhancements; align with Scheme rules and clinical protocols.
**Minimum Requirements**:
- Grade 12
- B Cur Nursing degree or Diploma in General Nursing with Midwifery, Psychiatry and Community Health/ Diploma in General Nursing and Diploma in Midwifery/ Diploma in General Nursing and (Diploma in ICU/ Theatre and/or Trauma will be an added advantage)
- 2 - 3 years experience in a private hospital setting
- 2 - 3 years experience working for a Medical Scheme (closed or open Scheme)
- Experience in claims assessing knowledge of ICD10 Codes, Tariff Codes, Modifiers, and critical Clinical protocols.
**Primary Duties**:
- Process various types of medical scheme claims through clinical protocols and scheme rules
- Provide excellent quality customer service to clients (electronically, walk in, telephonically and on roadshows)
- Updating policies and procedures through creative and innovative ideas as per scheme business processes utilizing available resources to improve operational inefficiencies
- Identifying gaps on the IT Admin System, logging requests for system enhancement to the DSP
- Compile monthly operational reports and provide to the Medical Scheme Supervisor for review
- Sound knowledge of ICD10 Codes, Tariff Codes, Modifiers, and critical clinical protocols
**Knowledge**:
- Medical Scheme background
- Knowledge of Medical Scheme Schemes No 131 of 1998 and its Regulation as amended
- Knowledge of Council of Medical Scheme
- Computer literacy (MS Office suite)
**Skills**:
- Good interpersonal skills
- Strong communication (written & Verbal)
- Team player
- Problem solving abilities
- Planning and organizing
- Report Writing Skills
**Attitude**:
- Accuracy and attention to details
- Time management
- Deadline orientated
- Self-starter
- Analytical thinker
- Customer oriented
- Integrity
- Innovative & creative
- Ability to work under pressure
