Claims Assessor ( Gap Cover)

Moladira Skills; Roodepoort; On-site; ZAR 180,000 - 300,000; Full time

Job summary

Moladira Skills is seeking a Claims Assessor to ensure Gap claims are accurately captured in the iMed system and processed within SLA. You will work in a healthcare and insurance environment, handling claims, data entry, and compliance with regulatory standards.

Ideal candidates have Matric with RE5, at least 3 years of relevant experience, and strong numerical, analytical and communication skills to deliver high-quality service to members and providers.

Qualifications

• Knowledge and application of relevant legislation.
• Knowledge and application of processes and procedures.
• Knowledge of scheme rules and contractual negotiations.

Responsibilities

• Follow procedures and cooperate with peers and leader for best possible service delivery.
• Defined legal, statutory and regulatory compliance is maintained at the required standards.
• Operational risk and governance structures, measures and frameworks are complied with.
• Contribute to cost savings within the department to assist with financial goals and targets.
• Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement.
• Rectify incorrect information on claims and communicate outcome.
• Maintain detailed records of claims and assessments.
• Assist with training and sharing of knowledge within the team and clients.
• Assist on the various Call centres and with call backs.
• Review and assess gap claims.
• Verify documentation and ensure all required information is completed.

Skills

Problem solving

Communication skills

Attention to accuracy and detail

Numerical ability

Multitasking

Data modelling and evaluation

Business writing skills

Adobe Creative Suite

Proficiency in Microsoft Office Suite

Education

Matric and RE5 Required

Tools

Adobe Creative Suite

Microsoft Office Suite

Job description

CLAIMS ASSESSOR

Position Purpose
To ensure that all paper Gap claims are accurately captured into the iMed system.

Experience

3 years relevant healthcare industry, short term insurance and credit data capturing and claims processing experience

Qualifications

Matric and RE5 Required

Accountabilities

Client service delivery and quality

• Follow procedures and cooperate with peers and leader for best possible service delivery

Compliance and Risk Management

• Defined legal, statutory and regulatory compliance is maintained at the required standards
• Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary

Financial Management

• Contribute to cost savings within the department to assist with financial goals and targets

Operating Model

• Conduct accurate and effective intervention/reconciliation of administration on all allocated claims
• Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement
• Continuously apply relevant rules
• Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims
• Rectify incorrect information on claims and es?
• Reconcile claims where required and communicate outcome
• Ensure correct payments to vendor or member
• Meet delivery objectives through working with other team members within and linked to the department / project
• Resolve operational performance variations and problems and elevate unresolved issues to higher levels
• Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery

Operational Implementation of Strategy

• Keep up to date with operational changes implemented in response to important external influences
• Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
• Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement.

Operational Leadership

• Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
• Engage in development, coaching and mentoring
• Support transformation through valuing diversity
• Behave in alignment with the Afrocentric values

Stakeholder Management

• Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies
• Identify, investigate, respond to and refer IT assessing queries appropriately
• Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved
• Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in

Position Specific Outputs

• Duplicate check claims received, and process claims and emails according to processes.
  
• Capture all claims received in accordance with relevant legislation and processes.
  
• Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
  
• Providing coding review and resolution on call centre queries
  
• Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
  
• Communicate with Stake holders
  
• Maintain clinical documents and processes
  
• Review and action QA reports and provide corrective actioning
  
• Assist with training and sharing of knowledge within the team and clients
  
• Assist on the various Call centres
  
• Assist with call centre call backs.
  
• Review and assess gap claims.
  
• Verify documentation and ensure all required information is completed.
  
• Communicate with clients and stakeholders to gather necessary information.
  
• Process claims efficiently and accurately.
  
• Maintain detailed records of claims and assessments.
  
• Collaborate with other departments.
  
• Assist with departmental Adhoc duties where required.

Position Specific Outputs 2

Competency Requirements

Knowledge:

• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedures
• Knowledge of scheme rules and contractual negotiations

Skill:

• Problem solving and decision making skills
• Business Writing Skills
• Communication Skills
• Computer Technology Skills
• Task Management
• Adobe Creative Suite
• Data modelling and evaluation
• Attention to Accuracy and Detail
• Numerical Ability
• Customer Focus
• Multitasking
• Strong analytical and problem solving skills
• Proficiency in Microsoft Office Suite
• Relevant systems knowledge and application