Claims Quality Specialist

2 days ago


Pretoria, Gauteng, South Africa Marx Enterprise Transformation Architecture Full time

Job Title: Claims Quality Assessor (ADMED) MMH-5

We are seeking a highly skilled Claims Quality Assessor to join our Admed department, where your role will be to quality assess all claims processed by the team, ensuring accuracy, completeness, and validity.

Key Responsibilities:
  • Quality assessing all claims processed by the Admed claims team in the OWLS system.
  • Validating personal information, clinical information, documents attached, and decision made on the claim.
  • Investigating claims flagged by the OWLS system as possible pre-existing conditions within 2 working days and completing a detailed register for each claim.
  • Conducting quality assessments on claims returned from external service providers post PMB and service provider negotiation.
Requirements:
  • Matric / Grade 12 qualification.
  • Basic medical qualification an advantage (e.g. nursing or similar).
  • MS Office computer skills.
  • At least 3 years medical aid or gap cover claims processing and assessing experience.
  • At least 2 years insurance experience.
  • Knowledge of local health and medical schemes industry, demarcation, and legislation governing the local health industry.
Duties and Responsibilities:
  • Assessing claims in accordance with practice guidelines, policy wording, and protocols.
  • Ensuring high level of service when liaising with individual and corporate customers, intermediaries, binder holders, and colleagues.
  • Delivering TCF principles across functions performed, with focus on Outcome 6.
  • Preparing weekly and monthly reports, trend data, and submitting to Quality assurance manager.

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