Dental Insurance Claims Administrator

**ABOUT DENIS**

Dental Information Systems (Pty) Ltd (DENIS) has been a leader in dental managed care services since 1996. Our extensive experience in dental risk management combined with cutting edge technology offers a world class service relevant to the Southern Africa market (South Africa, Botswana, Namibia).

DENIS currently provides dental managed care services to 11 medical scheme clients.

**ABOUT THE DENTAL INSURANCE BUSINESS**:
Separate to the DENIS business we offer dental insurance products through Denis Insurance Administrators (Pty) Ltd. Our services include claims and membership administration for Guardrisk and claim administration for Hollard. DENIS Insurance is a registered financial services company with licensing for Category 1, Life and Non-Life Personal lines.

**ABOUT THE POSITION**

An opportunity exists at Dental Information Systems (Pty) Ltd within our Insurance division for an Insurance Claims Administrator.

The incumbent will be based at our Head Office in Century City (Cape Town). We adopt a hybrid work model arrangement for this role.

The Dental Insurance Claims Administrator is responsible for managing the claims process for dental insurance policies, ensuring claims are submitted, tracked, and resolved in compliance with South African regulations.

This role requires a deep understanding of dental insurance products, the claims process, and relevant financial services legislation. A key requirement for this position is the successful completion of the Regulatory Exams and meeting the Fit and Proper standards as outlined by FAIS.

**Key responsibilities may include but are not limited to**:
1. Claims Submission and Processing
- Prepare and process dental insurance claims ensuring compliance with the Insurance Policy guidelines
- Verify patient treatment details and ensure all claims are submitted with the necessary supporting documentation, such as treatment plans, dental charts, and diagnostic images
- Follow up on claims through electronic and manual submission methods, ensuring adherence to insurance policy wording and processing timelines

2. Claims Follow-Up and Resolution
- Monitor, track, and resolve outstanding claims in a timely manner
- Handle appeals for denied claims, working within FAIS guidelines and submitting necessary documentation for reconsideration

3. Insurance Verification and Benefit Management
- Confirm patient insurance eligibility and benefit details post scheduled treatments, ensuring that all insurance information is accurate and up-to-date

4. Regulatory Compliance and Fit and Proper Requirements
- Ensure all insurance-related activities, including claims processing and patient communication, comply with the FAIS Act and FSCA regulations
- Maintain the Fit and Proper requirements as set out by the FSCA, including the completion of the relevant Regulatory Exams (RE5, RE1, etc.) within the prescribed timeframes
- Adhere to ethical standards and maintain a professional relationship with insurance providers, colleagues, and patients

5. Client Communication and Support
- Respond promptly to policy holder inquiries regarding their claims, explaining insurance coverage in layman's terms and managing expectations regarding claim status

6. Documentation and Reporting
- Assist with audits and quality control, ensuring that claims submissions adhere to both internal protocols and regulatory requirements

7. Regulatory Knowledge and Ongoing Development
- Stay up-to-date with changes in the South African dental insurance landscape, medical aid policies, and regulatory requirements as stipulated by the FSCA
- Participate in continuous professional development and training, maintaining awareness of any updates to FAIS, Fit and Proper requirements, and related legislation

**Critical Skills/ Competencies**
- Excellent Communication skills (both verbal and written) with the ability to explain complex insurance terms to patients clearly
- Assertiveness by demonstrating confidence and professionalism during engagements
- Strong Attention to Detail in data entry, insurance claims, and compliance processes
- Problem-Solving Skills to address claim issues, resolve disputes, and ensure timely payments
- Time Management skills with the ability to manage multiple claims and deadlines
- Customer-Oriented attitude with a focus on providing the best service to patients

**Experience**
- 2-3 year’s experience in a Claims Assessing or similar role
- Experience in healthcare insurance, financial or administration industry & knowledge of relevant legislative environment is highly desirable

**Education and Applicable Systems**
- Grade 12
- Relevant Tertiary Qualification (Diploma or Degree)
- RE5
- Class of Business Studies completed at least in Life and Non-Life

**Job Types**: Full-time, Permanent

Pay: R10 500,00 - R15 000,00 per month

Application Deadline: 2024/06/30