Clinical Claims Adjudicator

Rand Mutual - RMA; Parktown (NC); On-site; USD 21,000 - 31,000; Full time

Job summary

Rand Mutual Assurance is seeking a Clinical Claims Adjudicator to support adjudication of disease and accident claims in line with COID Act and Non-COID VAPS policies. The role involves updating ICD10 codes, pre-authorisation adjudication, and managing complex claims with independent critical thinking to assess impairment.

You will coordinate with medical service providers, assess treatment authorisation requests, and ensure accurate claims management.

Qualifications

• Requires a Health Sciences degree at NQF level 7 and RE5 certification.
• Postgraduate diploma in occupational health is advantageous.
• Experience in medical claims and COID/FAIS framework is essential.

Responsibilities

• Process and adjudicate disease and accident claims in line with COID Act and VAPS policies.
• Review ICD10 codes and liaise with service providers for outstanding reports.
• Evaluate authorisation requests and ensure proper case management of claims.
• Manage costs related to authorisation and claims estimates for open claims.
• Assess claims nearing Maximum Medical Improvement and update accordingly.
• Communicate repudiated claims with clear rationale to claimants and maintain records.

Skills

Communication skills

Stakeholder engagement

Clinical judgement

Medical aid/insurance experience

ICD10 knowledge

Education

NQF Level 7: Health Sciences degree

Postgraduate diploma in occupational health

RE5 certificate

Tools

MS Office

Job description

THE JOB AT A GLANCE

As the Clinical Claims Adjudicator, you will be reporting to the Team Leader: Clinical Claims Adjudication. You will be responsible for providing support on the effective and efficient adjudication of disease and accident claims in line with COID Act and Non-COID VAPS policies (i.e., updating and reviewing ICD10 codes, pre-authorisation adjudication for out of hospital treatments, case management of all accident claims and claims estimates monitoring and management). The role requires an individual with critical thinking that is able to work independently and triangulate medical information to make claims decision on impairment assessment.

Job Description

As the Clinical Claims Adjudicator, you will be reporting to the Team Leader: Clinical Claims Adjudication. You will be responsible for providing support on the effective and efficient adjudication of disease and accident claims in line with COID Act and Non-COID VAPS policies (i.e., updating and reviewing ICD10 codes, pre-authorisation adjudication for out of hospital treatments, case management of all accident claims and claims estimates monitoring and management). The role requires an individual with critical thinking that is able to work independently and triangulate medical information to make claims decision on impairment assessment.

What You Will Do

Claims processing and adjudication

• Review and update ICD10 codes on all claims in line with relevant protocols and accepted liability. Review medical reports and medical investigation report on the system for acceptance or rejection
• Liaise with medical service providers to submit outstanding medical reports in order to update claims progress status timeously and ensure that claims estimates remain within the acceptable estimates
• Evaluate treatment authorisation to either decline or approve the treatment authorisation request in line with the COIDA gazette. Ensure that the claims are properly case managed based on the treatment protocols that they are receiving versus the injury sustained or disease
• Manage costs associated with the authorization and claims estimates for all open claims
• Assess and update claims close to exceeding their Maximum Medical Improvement (MMI). Evaluate and analyse medical reports linked to claims and ensure claims are updated in accordance with medical reports received
• Communicate (via email and phone call) repudiated claims to claimants and provide reasons/rationale thereof for disease cases
• Adjudicate, calculate and award permanent disability in line with delegation of authority policy, AMA Guide and COID Act instructions
• Adjudicate and recommend permanent disablement to medical advisors if disability impairment is above 10% for confirmation and once confirmation received, process the claim further and refer back to the claim owner
• Liaise and refer disease claims to medical advisors
• Manage high risk and complex cases
• Close management and monitoring with claims above 500 000K estimated cost per claim
• Support claims team with complex claims queries from external stakeholders.

Attend to queries related to claims under management

• Provide Customer Services aligned to TCF (Treating Customer Fairly)
• Attend to queries related to claims and elevate to medical advisors where needed.

Medical report writing

• Triangulate and summarize medical information received in order to refer claims to medical advisors and/or Technical Committee for claims decision (extension of MMI beyond 2years or impairment assessment above 10%).

What You Will Get In Return

We offer great opportunities for personal and professional development in a stable company that is 132 years strong. The role comes with a competitive salary package and various benefits. Furthermore, you will be part of a dedicated group of colleagues who value teamwork and collaboration.

Turnaround time

The shortlisting process will only start once the advert due date has been reached. The time taken to complete this process will depend on how far you progress within the recruitment process and the availability of our managers. Kindly note that should you not receive a response within 21 days, please consider your application unsuccessful.

Closing date: 13th October 2026

13th October 2026

Our Commitment to transformation:

In accordance with the employment equity plan of Rand Mutual Assurance and its employment equity goals and targets, preference may be given, but is not limited, to candidates from under-represented designated groups.

Job Requirements

What You'll Bring To The Table

• NQF Level 7: Degree in Health Sciences (Nursing, Occupational Therapy and Physiotherapy, Clinical Associates (Essential)
• Post graduate diploma in occupational health (Advantageous)
• RE5 Certificate (Essential - This is a FAIS Compliant role)
• 3 – 5 years’ in-hospital clinical/case management/medical aid claims environment experience (Essential)
• Group Life Insurance experience (Advantageous)
• Occupational Health experience (Essential)
• Clinical Judgement
• Medical Aid/Insurance experience (Essential)
• ICD10 knowledge
• MS Office
• COID Act and its instructions
• Occupational Health and Safety Act
• AMA Guide
• Disability Impairment Assessment
• Claims case management
• Stakeholder engagement
• Communication skills (who do they communicate with)
• Knowledge of business policies, processes and procedures, legal compliance.