Medical Claims Specialist

1 month ago


Cape Town, Western Cape, South Africa Nambiti Technologies Full time

Nambiti Technologies is seeking a skilled Medical Claims Review Officer to join our team.

About the Role

The successful candidate will be responsible for auditing and reviewing medical claims, ensuring that they are valid and in accordance with company guidelines and the company Act.

You will work closely with stakeholders to promote good working relations and provide training on new developments.

In this role, you will also be responsible for approving medical expenses in accordance with relevant DOA, determining the level of care based on functional ability, and preauthorizing procedures.

Key performance areas include:

  • Audit & review medical bills, including analysis of claimed items/services in correlation with available tariff structures and ICD 10 /CPT 4 codes.
  • Requesting motivation for unreasonable accounts, flagging rejected items/services, and recommending solutions to department responsible for processing payments.
  • Auditing medical claims and assisting in technical aspects of bill review, ensuring that accounts submitted to the Fund from service providers are valid in terms of company guidelines and the company Act.
  • Assessing and monitoring claims to curb over servicing or abuse and fraudulent claims, reducing future healthcare cost and improving efficiencies by analysing trends in utilization of services.

To be successful in this role, you will need:

  • Bachelor's Degree or Advanced Diploma in nursing/ Allied Health Professions or related qualification.
  • Registration with the relevant Health professions council.
  • Relevant 3 years' experience in a medical field.

We offer a competitive salary of R350,000 - R450,000 per annum, depending on experience, as well as opportunities for career growth and professional development.



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