Clinical Audit Clerk

Momentum Health; Cape Town; On-site; ZAR 300 000 - 400 000; Full time

Job summary

A leading health services provider in Cape Town seeks a Medical Aid Claims Consultant to manage client queries and claims efficiently. The role requires a matric qualification, with further education being advantageous, and 3-5 years of experience in the medical aid industry is essential. Candidates should also possess strong communication skills and a solid understanding of medical claims regulations. The position emphasizes client satisfaction and teamwork within the department while ensuring Service Level Agreements are met.

Qualifications

• Must have 3 - 5 years in the medical aid industry.
• 2 - 3 years Claims processing and query management experience is essential.
• Understanding of CMS, DoH, BHF, Private hospitals regulations.

Responsibilities

• Identifying risks and escalating anomalies.
• Maintaining service delivery for client retention and satisfaction.
• Ensuring adherence to Service Level Agreements.

Skills

Claims processing

Client communication

Risk identification

Education

Matric

Relevant tertiary qualification

Claims School training

Job description

Introduction

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

Disclaimer

As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose

To provide an effective and efficient service to clients by receiving, evaluating and responding to Medical Aid claims queries timeously.

Requirements

• Matric (essential)
• Relevant tertiary qualification (advantageous)
• Claims School training (essential)

Experience

• 3 - 5 years in the medical aid industry (essential)
• 2 - 3 years Claims processing and query management experience within the medical aid industry (essential)

Knowledge

• Understanding and knowledge of the interpretation and application of CMS, DoH, BHF, Private hospitals, etc

Duties & Responsibilities

• Identifying risks and possible anomalies to the company and escalating accordingly.
• Maintaining a consistent service delivery to ensure client retention and satisfaction.
• Ensuring Service Level Agreements are met and exceeded at all times.
• Providing first time resolution on queries of a complex nature.
• Dealing promptly with client requests in a competent, efficient and professional manner.
• Driving and supporting effective teamwork within the department.
• Engaging in appropriate training interventions to promote own professional development.
• Recording all queries and interactions with customers onto the workflow and reflection systems.
• Liaising with the Clinical Advisors i.e. Medical Advisors, Radiologist, Pathology accordingly.
• Collaborating with relevant departments in ensuring resolution to complex queries.
• Applying in-depth knowledge and interpretation of both SAMA (South African Medical Association) and GEMS guidelines, including knowledge of ICD and CPT coding.
• Applying the Scheme specific Rules to inappropriate claims e.g. scheme exclusions on (QES / MES).
• Providing clinical interpretation and appropriateness of claims in accordance with Scheme Rules.
• Positively influencing and participating in change initiatives.

Competencies

• Good written and verbal communication
• Business Acumen
• Client/ Stakeholder Commitment
• Drive for Results
• Leads Change and Innovation
• Collaboration
• Impact and Influence
• Works independently
• Diversity and Inclusiveness