Claims Assessor

**Introduction**

Processing of medical expense shortfall (gap cover) claims in accordance with stipulated service levels and in terms and conditions of cover as defined in policy wording.

**Role Purpose**

Processing of medical expense shortfall (gap cover) claims in accordance with stipulated service levels and in terms and conditions of cover as defined in policy wording.

**Requirements**:

- Matric
- Basic medical qualification an advantage (e.g., nursing or similar qualification)
- Computer Literacy (MS Word, Outlook, and Excel)
- FAIS Fit and Proper including RE5
- At least 2 years medical or short-term health and accident insurance claims handling experience
- At least 2 years client servicing experience
- A good knowledge of the local healthcare industry

**Duties & Responsibilities**
- Ensuring that the principles and outcomes of TCF (Treating Customers Fairly) are practised and achieved in all duties performed and services provided to Admed customers
- Ensuring the cradle-to-grave coordination of all gap claims received electronically from contracted medical schemes with the objective of achieving an entirely seamless claims experience for mutual customers
- Dealing with client and medical scheme queries as and when they arise within the stipulated timeframe
- Ensuring that claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed SLA’s
- Ensuring the ongoing successful importing of claims data into the claim administration system
- Ensuring that all registered claims are assessed and administered effectively and efficiently in terms of the relevant and prevailing legislation and policy wording
- Accurately and completely capturing the clinical details of a claim on the claim administration system on the same day or within 2 working days of receipt
- Prioritizing claims where outstanding documentation has been received - ensuring that these documents are captured within 48 hours of receipt
- Assessing claims in accordance with practice guidelines, policy wording and protocols
- Finalisation and forwarding of claims to the quality assurance team for approval / rejection
- Ensuring prompt handling and feedback on claims
- Responding to capture queries received within 48 hours of receipt
- Detecting and acting on potential fraudulent claims
- Ensuring a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, Medical schemes and colleagues
- Ensuring that the principles of TCF are delivered across every function performed, with a specific focus on the achievement of TCF Outcome 6 (Customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim or make a complaint)
- Where relevant, engaging with the Admed claims team and the respective medical schemes in respect of changing benefits and protocols, updating system rules and data file specifications
- Liaising with the contracted medical schemes in respect of all the claim's integration matters, including challenges, changes, etc
- Liaising with the Guardrisk IT Department and its appointed external developers in respect of system requirements, changes and problems
- Monitoring of claims-related system communication with customers, to ensure that customers are always kept up to date during the claims process

**Competencies**
- Results and solutions driven
- Strong focus on client centricity and service excellence
- Strong problem solving and decision-making capability
- Organised and focused
- Analytical skills with attention to detail
- Resilience and ability to work under pressure
- Adaptability and self-discipline
- Effective communication skills and ability to professionally manager customers
- Disciplined and reliable
- A team player