Medical Aid Claims Specialist

2 weeks ago


Johannesburg, Gauteng, South Africa Palesa Mbali Group Full time

Job Title: Medical Aid Claims Specialist


Job Summary: We are seeking a highly skilled Medical Aid Claims Specialist to join our team at Palesa Mbali Group. The ideal candidate will have a strong background in medical aid claims processing and excellent communication skills.


Key Responsibilities:



  • Ensure defined legal, statutory, and regulatory compliance is maintained at the required standards
  • Operational risk and governance structures, measures, and frameworks are complied with and necessary action is taken to address issues when necessary
  • Ensure that payments are processed at the correct rate and against available benefits
  • Investigate all documentation, correct where required, and link to member records
  • Analyse and correct incorrect payments and identify the reason for non-payment
  • Apply the Quality Analysis checklist to the processing of claims
  • Provide comprehensive and accurate feedback to clients
  • Identify system constraints and escalate accordingly
  • Assist in Call Centre/other areas when required
  • Ensure that quality control targets are met
  • Meet delivery objectives through working with other team members within and linked to the department/project
  • Resolve operational performance variations and problems and escalate unresolved issues to higher levels
  • Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery
  • Ensure appropriate, active, and informative relationships with customers and relevant stakeholders are successfully achieved
  • Address customer or stakeholder complaints in alignment with policies and procedures and ensuring customer/stakeholder buy-in

Requirements:



  • Problem-solving and decision-making skills
  • Business writing skills
  • Communication skills
  • Computer technology skills
  • Task management
  • Adobe Creative Suite
  • Data modelling and evaluation
  • Attention to accuracy and detail
  • Numerical ability
  • Customer focus
  • Relevant systems knowledge and application

Experience and Qualifications:


1-2 years' experience in the medical aid industry is essential, business writing skills in English are required, investigative, communication, and interpersonal skills are required, and in-depth working knowledge of client rules will be advantageous



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