Claims Care Specialist

AfroCentric Group; Wes-Kaap; On-site; ZAR 30 000 - 60 000; Full time

Job summary

An established industry player is seeking a detail-oriented professional to audit and process hospital claims. This role is crucial in ensuring compliance and accuracy in payment processes while supporting the operational team. Candidates should have a strong background in customer service and healthcare, with excellent communication skills. Join a forward-thinking organization that values diversity and transformation, contributing to a team dedicated to delivering quality service and maintaining high standards in the healthcare sector.

Qualifications

• 5+ years in customer service and operations.
• Minimum 2 years in the health industry.

Responsibilities

• Auditing and processing hospital claims payments.
• Ensuring compliance with legal and regulatory standards.

Skills

Customer Service

Communication Skills

Root Cause Analysis

Operational Management

Education

Registered Nursing Qualification

Job description

What will you do?

Position purpose:

To accurately audit, authorise, and process the payment of hospital and associated event claims. Ensure that all patient treatments, materials, and equipment usage for each claim adhere to established claim rules and regulations.

Play a critical role in maintaining compliance and ensuring the integrity and accuracy of the claim’s payment process.

Responsibilities include:

• Assisting Support Service Teams with the audit of hospital claims assessments.
• Providing general support to the team, including outbound telephonic calls to hospitals.

Accountabilities

Client service delivery and quality:

• Following procedures and cooperating with peers and leaders to deliver the best possible service.

Compliance and Risk Management:

• Maintaining compliance with legal, statutory, and regulatory standards.
• Adhering to operational risk, governance structures, measures, and frameworks, and taking necessary actions to address issues.

Financial Management:

• Contributing to departmental cost savings to support financial goals.

Operating Model:

• Meeting delivery objectives by collaborating with team members within and across departments.
• Resolving operational performance issues and escalating unresolved problems.
• Ensuring targets are met and supporting team efforts for successful delivery.

Operational Implementation of Strategy:

• Staying updated with operational changes due to external influences.
• Delivering work that supports operational quality standards and departmental priorities.
• Identifying and implementing continuous improvement opportunities.

Operational Leadership:

• Performing within human capital frameworks and policies to meet standards and objectives.
• Engaging in development, coaching, and mentoring.
• Supporting transformation and valuing diversity.
• Behaving in alignment with Afrocentric values.

Stakeholder Management:

• Building and maintaining active, informative relationships with customers and stakeholders.
• Addressing complaints according to policies, ensuring customer/stakeholder buy-in.

Qualifications and Experience:

• At least 5 years in customer service and operations.
• Minimum 2 years in the health industry.
• Excellent communication skills with 2-3 years of experience.
• Root Cause Analysis experience spanning 3-5 years.
• Hospital administration/assessment experience for 2-3 years.

Qualifications:

• Registered Nursing Qualification and registration with the SA Nursing Council.

Turnaround Time:

Shortlisting begins after the application deadline. The process duration depends on your progress and line managers' availability.

Our Commitment to Transformation:

AfroCentric is dedicated to transformation and diversity. Our Employment Equity plan will be considered during recruitment. We aim for a diverse, inclusive workforce that reflects societal demographics and includes people with disabilities.

If you do not hear from us within a month, your application was unsuccessful.