Medical Claims Specialist
2 weeks ago
A Medical Claims Specialist is required to support the management team in the client's Management department and attend to escalated queries. The role involves ensuring the prompt resolution of member queries regarding all medical aid claims, telephonically and in writing.
Key Responsibilities
- Maintain defined legal, statutory, and regulatory compliance at the required standards
- Ensure operational risk and governance structures, measures, and frameworks are complied with and necessary action is taken to address issues when necessary
- Process payments at the correct rate against available benefits
- Investigate all documentation, correct where required, and link to member records
- Analyze and correct incorrect payments and identify reasons for non-payment; apply quality analysis checklists to claim processing
- Provide comprehensive and accurate feedback to clients
- Identify system constraints and escalate accordingly
- Assist in Call Centre/other areas when required
- Meet quality control targets by working with other team members within and linked to the department/project
- Resolve operational performance variations and problems, escalating unresolved issues to higher levels
- Meet delivery targets/objectives and operate in a supportive manner to achieve successful delivery
- Establish and maintain active relationships with customers and relevant stakeholders
Required Skills
- Problem-solving and decision-making skills
- Business Writing Skills
- Communication Skills
- Computer Technology Skills
- Task Management
- Adobe Creative Suite
- Data modeling and evaluation
- Attention to accuracy and detail
- Numerical Ability
- Customer Focus
- Relevant systems knowledge and application
Requirements and Qualifications
The ideal candidate will have 1-2 years of experience in the medical aid industry, with business writing skills in English being essential. Investigative, communication, and interpersonal skills are required, with an in-depth working knowledge of the client's rules advantageous. Claims processing experience is essential.
We offer a competitive salary of R180,000 - R220,000 per annum, depending on experience, plus additional benefits including medical aid, provident fund contributions, and annual leave.
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