Claims Support Specialist

**Main purpose of the Job**

**Provide support to clients relating to claims and claims queries by accurately capturing and assessing claims including in-hospital related events. Educate and resolve client queries to ensure a world class customer experience is provided with all client interaction.**

**Claims handling**
- Timeous and accurate capturing of claims (80 claims per day minimum)
- Scanning and filing of paper claims
- Answer phones and resolve claim queries within determined SLA
- Transfer customer calls to appropriate staff, where necessary
- Identify, research, and resolve customer/provider issues using the computer system
- Follow-up on customer/provider enquires not immediately resolved, within determined SLA’s
- Complete call logs and reports
- Follow and adhere to claim processes, procedures, and protocol
- Recognize, document, and alert the supervisor of trends with processing of claims
- Recommend process improvements
- Focus on first call resolution as far as possible
- Provide update on claims to manager daily
- Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim
- Ensure daily stats are updated and sent to supervisor/ manager at the end of each day
- Assessing of claims according to standard operating procedure and company protocols
- Ensure quality assurance standards are met as per company guidelines.
- Approval of hospital claims using knowledge of ICD10 codes and procedure codes (CPT)
- Other duties as assigned from time-to-time
- Improve client service experience, create engaged clients, and facilitate organic growth
- Manages tasks allocated through omni-channel platforms.
- Handle complex and escalated client service issues
- Build/maintain rapid channel of communication to client in case of service-related issues and events
- Represent the “Voice of the Customer”
- Create a culture of Customer/Client Centricity
- Ensure adherence to standard operating procedures in all engagements.
- Identify client needs and actively find solutions that will assist the client in having the best possible client experience.
- Educate clients on product offering and use methods that allow the business to resolve the queries as a first call resolution.
- Ensure follow up and follow through on all client queries
- Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Head.
- Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
- Leverage team success to drive all initiatives and experiences with clients.
- Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
- Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client’s queries from end-to-end to ensure a world class client service experience.
- Support cross functional work areas targeted to resolve issues raised by clients.
- Proactively gather client feedback to optimize client experience

**Quality, Consistency and Compliance**
- Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
- Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
- Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
- Ensure adherence to all relevant legislation and regulations as set out by the Company, Regulatory Board, and the Financial Services industry.

**Work Collaboratively**
- Build a culture of respect and understanding across the organisation
- Recognise outcomes which resulted from effective collaboration between teams
- Build cooperation and overcome barriers to information sharing, communication, and collaboration across the organization
- Facilitate opportunities to engage and collaborate with internal and external stakeholders to develop joint solutions

**Self
- Management**
- Follow through to ensure that personal quality and productivity standards are consistently and accurately maintained
- Plan and prioritise, demonstrating abilities to manage competing demands
- Demonstrate abilities to anticipate and manage change
- Demonstrate flexibility in balancing achievement of own objectives with abilities to understand and respond to organizational needs

**Minimum Academic, Professional Qualifications & Experience required for this position**
- Grade 12 with English and a second language
- RE5 (preferred)
- Knowledge of ICD10 codes and Procedure codes (CPT) - highly advantageous
- Knowledge of Medical billing (advantageous)
- Previous case management background preferred/ Medical Aid experience (highly advantageous)
- Relevant qualification in related field advantageous
- Minimum of 3 - 5 years customer service and industry