Claims Specialist

-Introduction

Metropolitan is one of the oldest financial services brands in South Africa. With a 116-year legacy of serving the communities in which it operates, Metropolitan represents true empowerment in serving Africa's people through affordable financial solutions that create financial growth and security.
Role Purpose

To provide an effective and efficient service to clients by receiving, evaluating, and responding to telephonic/electronic inquiries timeously.
Requirements
- Grade 12/Matric.
- Relevant tertiary qualification would be an advantage, Customer Relationship Management, Business.
- Management, Project Management, and Operations Management.
- Claims School Training.
- 2 -3 years in the medical aid industry:

- 2 - 3 years Claims processing experience within the medical aid industry.
- 2 - 3 years of query management experience.
- 2 - 3 years of client service experience.
- Good understanding of the MH systems would be an advantage.
Duties & Responsibilities
- Interaction with the Clinical Advisors i.e. Medical Advisors, Radiologist, Pathology.
- Internal communication and relationship building.
- Building and nurturing the SPN partnership.
- Extensive interaction with Customer Experience
- Communicates and interacts with Bureaus and Service providers.
- Deliver meaningful and relevant feedback and communication.
- Extensive communication within the GEMS BU as well as external service providers and bureaus.
- Scrutinize all suspected inappropriate/ irregular claims appearing on the Metropolitan Expert Tool (QES /MES), (GPs, Specialists, Allied Health and Radiologist) and ensure appropriate processing.
- Investigate and action Adhoc written inquiries from the business units.
- Interact with the various medical advisors on an ongoing basis and coordinate the flow of queries.
- Address correspondence pertaining to investigations and follow-ups.
- Identify trends from QES/MES activities and refer Providers' Profiles to forensics for investigation.
- Provide clinical interpretation and appropriateness of claims in accordance with Scheme Rules.
- Make recommendations to the team leader/manager regarding new rules to be added to QES / MES rules engine.
- Identify new risk areas and make recommendations to team leaders/managers.
- Respond to written communication and investigate queries relating to Clinical Audit Department functions.
- Liaise with Client Service, Claims, and CMS regarding correspondence queries.
- Check doctor claim history.
- Determine what is settled and what must still be processed for payment.
- Do the necessary rejections using the correct rejection codes.
- Do necessary reversals where required.
- Routing of claims or documents to the relevant departments.
- Reprocessing of accounts from the Y- Pends.
- Loading of appliance filters once approved by MHRS and Y-Pend to the filter queue for reprocessing.
- Loading a PMB fax filter on the filter screen once approved by MHRS and Y- Pend to the filter queue for reprocessing.
- Hospital claims reversal requests received from MHRS to be reversed with reversal code 9929.
- Review all medicines with Nappi codes.
- Reversal and reprocessing and submitting to MediKredit.
- Refer urgent special batches for urgent queries.
- Reprocessing of Ex
- gratia claims that are received from the ex-gratia department and provide feedback once completed.
- Loading of rule and auth filters for Ex-gratia.
- Load filters related to Appliance Approvals, Ex Gratia, PMB and Exclusions.
- Provide ex-gratia with scheme rates when required.
- Scrutinize, review, reverse and reprocess claims received as complaints from Customer Experience and Fund.
- Provide written and/or telephonic responses to Customer Experience Team.
- Liaise with internal clients as well as external clients (Members and Providers).
- Management including knowledge of ICD and CPT coding.
Competencies
- Business Acumen.
- Collaboration.
- Client/ Stakeholder Commitment.
- Impact and Influence.
- Drive for Results.
- Works independently.
- Leads Change and Innovation.
- Diversity and Inclusiveness.

Policy

We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.