Claims Assessor

3 days ago

Sandton, South Africa Guardrisk Full time

**Introduction**
- To process medical expense shortfall (gap cover) claims in accordance with stipulated service levels and the terms and conditions of cover as defined in the policy wording.

**Disclaimer**
- As an applicant, please verify the legitimacy of this job advert on our company career page.

**Role Purpose**
- To process medical expense shortfall (gap cover) claims in accordance with stipulated service levels and the terms and conditions of cover as defined in the policy wording.

**Requirements**:

- Matric /Grade 12
- Basic medical qualification an advantage (e.g. nursing or similar qualification)
- FAIS Fit and Proper including RE5
- At least 2 years medical aid or gap cover claims processing and assessing experience
- At least 1 year insurance experience
- Basic knowledge of the local health and medical schemes industry, as well as an awareness of demarcation and legislation governing the local health industry.

**Duties & Responsibilities**
- Receive new Seamless claims via Secured sites, importing them into the system - including the updating of members’ personal details - onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.
- Ensure claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed SLA’s.
- Accurately capture the clinical details of a claim on the claims administration system (OWLS) on the same day or within 2 working days of receipt.
- Prioritise claims where outstanding documentation has been received, ensuring these documents are captured within 48 hours of receipt.
- Assess claims in accordance with practice guidelines, policy wording, and protocols.
- Finalize and forward claims to the quality assurance team for approval or rejection.
- Ensure prompt handling and feedback on claims.
- Respond to capture queries within 48 hours of receipt.
- Detect and act on potential fraudulent claims.
- Maintain a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, and colleagues.
- Provide support to the front-line team for inbound call overflows, query handling, complaints handling, and mailbox coordination when requested.
- Ensure the principles of Treating Customers Fairly (TCF) are delivered across all functions, with a specific focus on achieving TCF Outcome 6 (ensuring customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim, or make a complaint).

**Competencies**
- Results and solutions driven.
- Strong focus on client centricity and service excellence.
- Strong problem-solving and decision-making capabilities.
- Organized and focused.
- Analytical skills with attention to detail.
- Resilient and able to work under pressure.
- Adaptable and self-disciplined.
- Good communication skills and the ability to professionally manage customers.
- Disciplined and reliable.
- A team player.
- Computer Literacy (MS Word, Outlook and Excel).
- Willing to go beyond the normal working day to achieve target service levels

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