Claims Specialist | TALENT POOL MMH251114-12

1 day ago

Sandton, Gauteng, South Africa Momentum Full time

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.

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)

Duties and 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.

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