Claims Specialist

1 week ago

Sandton, Gauteng, South Africa Momentum Group Limited Full time R900 000 - R1 200 000 per year
Introduction

Through our client-facing brandsMomentum Group, with Multiply(wellness and rewards programme),and our other specialist brands,including Guardrisk and ErisProperty Group.The group enablesbusiness and people from all walksof life to achieve their financialgoals andl ife aspirations. We helppeople grow their savings, protectwhat matters to them and invest forthe future. We help companies andorganisations care for and rewardtheir employees and members.



Role Purpose

To lead the resolution of high-level and escalated queries, retain the current membership base, and take responsibility for the quality, timely delivery, and appropriateness of the team's recommendation.



Duties & Responsibilities

PROCESS

  • Review submitted claims to ensure accuracy and completeness, facilitating the determination of compensation.
  • Accurately process incoming claims within the defined service level agreement.
  • Evaluate and process claims and payments according to predetermined standards and rules.
  • Identify and reject duplicate claims to prevent duplication of compensation.
  • Coordinate or conduct investigations on complex claims, make informed decisions based on findings, and approve or reject claims accordingly.
  • Assist clients and internal stakeholders with queries related to claims.
  • Conduct quality control checks to minimize error rates in claim processing.
  • Escalate queries requiring further investigation and provide timely feedback to clients.
  • Generate reports and provide internal clients with updates on the status of claims.
  • Provide clear reasons for rejecting claims based on investigations and contractual obligations.

CLIENT 

  • Offer authoritative expertise to clients and stakeholders regarding claims matters.
  • Foster and maintain strong relationships with clients and internal and external stakeholders.
  • Fulfill service level agreements with clients and stakeholders to effectively manage client expectations.
  • Make recommendations for enhancing client service and ensuring fair treatment within the scope of responsibility.
  • Actively participate in creating a culture that values relationships, encourages feedback, and delivers exceptional client service.

PEOPLE

  • Develop and maintain productive and collaborative relationships with peers and stakeholders.
  • Actively contribute to and support change initiatives within the organization.
  • Continuously enhance professional expertise in terms of industry knowledge, legislation, and best practices.
  • Contribute to continuous innovation by sharing and implementing new ideas.
  • Take ownership of career development and drive personal growth.

FINANCE

  • Contribute to the financial planning process within the designated area.
  • Identify opportunities to improve cost-effectiveness and operational efficiency.
  • Manage financial and other resources under your control with diligence and responsibility.
  • Provide input into risk identification processes and communicate recommendations in the appropriate forums.


Requirements
  • Matric
  • Computer literate.
  • Comprehensive knowledge of all aspects of medical aid assessing is essential.
  • Working on the Oracle platform is an advantage.
  • Knowledge of relevant legislation and industry regulations
  • Knowledge of the claims assessment process (e.g., paper and EDI)
  • Knowledge of the relevant scheme or product rules
  • Knowledge of relevant operating systems and tools
  • 3 - 5 years medical aid claims administration or related experience
  • Exposure to the insurance industry (preferred)


Competencies
  • Attention to detail and accuracy
  • Problem solving ability
  • Ability to function effectively withina team.
  • Ability to work under pressure.
  • Consistently works to meetexpectations.
  • Resolves client problems within hisor her job scope.

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