Consultant:Claims Management

PPS; Centurion; On-site; ZAR 300,000 - 450,000; Full time

Job summary

A healthcare administration company is seeking a Claims Assessor to analyze and process claims accurately. The role requires at least 2 years of relevant experience in medical scheme administration, strong attention to detail, and excellent communication skills. Candidates must be knowledgeable about medical scheme rules and legislation, ensuring all claims meet the set standards. This position is critical for maintaining the quality of claims processing and adherence to regulations.

Qualifications

• 2 years of Medical Scheme Administration experience is essential.
• 2+ years of assessing experience is essential.
• Extensive understanding of Administration System required.
• Knowledge of Reference Price List necessary.
• In-depth knowledge of Medical Scheme Rules is essential.

Responsibilities

• Reconcile member or provider claims received.
• Accurate daily assessing of targets.
• Manage quality error percentage.
• Ensure consistent application of set standards and Scheme Rules.
• Escalate requests for corrections to relevant Consultant.

Skills

Medical Scheme Administration

Attention to detail

Time management

Good Communication

MS Office

Education

Grade 12

Tertiary Qualification

Job description

Job Description,

To analyze, reconcile, process information on a Claims account. To assess various type of claims submitted electronically / paper or received via fax or e-mail. Assessing must meet both quality and quantity set standards. To do corrections on accounts as requested by other departments or the Scheme. To complete Reversals as requested by Internal Clients or any other third parties.

, Requirements,

• Grade 12
• Tertiary Qualification
  
  

Experience

• Medical Scheme Administration Experience 2 years essential
• Assessing experience 2 years plus essential
• Extensive understanding of the Administration System essential
• Knowledge of Reference Price List essential
• In-depth knowledge of Medical Scheme Rules essential
• MS Office
• Medical Scheme Act essential
• Knowledge of Medical Aid Legislation and regulations essential
• Knowledge of ICD 10 codes essential
• Knowledge of PMB legislation essential
  
  

, Duties and Responsibilities,

• Reconcile member or provider claims received.
• Accurate daily assessing of targets.
• Manage quality error percentage.
• Ensure consistent and excellent application of set standards and Scheme Rules.
• Excellent administrative skills e.g. daily record keeping.
• Escalate requests for corrections to relevant Consultant.
• Follow up and resolve routed enquiries.
• Good Communication
• Good administration skill’s, including record keeping and the ability to work under pressure
• Must maintain a high level of productivity to asses claims daily targets set
• High attention to detail in order to identify system risks or process shortfalls
• Must be quality aware and quantity orientated
• Operating System knowledge
• Excellent time management in order to manage deadlines
• Excellent in query resolution