Claims Specialist | TALENT POOL MMH251114-12

Momentum; Sandton; Vor Ort; ZAR 180.000 - 260.000; Vollzeit

Zusammenfassung

Momentum in Johannesburg/Sandton seeks an experienced medical aid claims administrator to lead resolution of escalated queries and ensure accurate, timely processing of claims in line with policy rules.

You will assess claims, coordinate investigations on complex cases, provide updates to clients and stakeholders, and maintain high service levels while upholding compliance with industry regulations.

Qualifikationen

• Matric/grade 12 or equivalent.
• Computer literacy is essential for daily tasks.
• Comprehensive knowledge of medical aid assessing.
• Experience with Oracle is advantageous.
• Knowledge of legislation and industry regulations.
• Knowledge of claims assessment process (paper/EDI).
• Familiarity with relevant scheme/product rules.
• Experience with operating systems and claim processing tools.
• 3–5 years in medical aid claims administration or related work.
• Exposure to the insurance industry is preferred.

Aufgaben

• Review submitted claims to ensure accuracy and completeness.
• Process incoming claims within the defined service levels.
• Evaluate and process claims and payments as per standards.
• Identify and reject duplicate claims to prevent overpayment.
• Coordinate investigations on complex claims and make informed decisions.
• Assist clients and internal stakeholders with queries on claims.
• Conduct quality control checks to minimize errors in processing.
• Escalate queries requiring further investigation and provide feedback.
• Generate reports and update clients on claim status.
• Provide clear reasons for rejecting claims based on investigations.

Kenntnisse

Computer literacy

Medical aid claims knowledge

Claims processing knowledge

Ausbildung

Matric

Tools

Oracle platform

Operating systems

EDI systems

Jobbeschreibung

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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