HEALTHCARE CLAIMS ADJUSTOR

Heya South Africa; Johannesburg; On-site; ZAR 300,000 - 520,000; Full time

Job summary

Heya South Africa is seeking an experienced Healthcare Claims Adjustor to join our team in Johannesburg. You will handle U.S. healthcare claim processing, coding, and benefit-plan rules for a U.S.-based administrator, supporting self-funded employer groups.

You should understand claim processing systems (HealthRules Payer preferred), medical coding, and have strong communication and independent work skills in a fast-paced environment.

Qualifications

• Experience with claims processing systems required; HealthRules Payer preferred.
• Knowledge of healthcare claims, medical coding, and benefit plan rules.
• Strong critical thinking and independent decision making.
• Excellent written and verbal communication skills.
• Ability to manage multiple issues in a fast-paced environment with deadlines.
• Comfortable working independently for most of the day.
• Proficiency in Microsoft Office and web-based software; learn proprietary systems.
• High School diploma or GED required.

Responsibilities

• Reviewing and assessing incoming healthcare claims for accuracy and completeness.
• Adjudicating claims and processing payments to providers per plan rules.
• Collaborating with Claims Supervisor, Account Managers, and QA teams.
• Ensuring timely processing within turnaround targets.
• Applying medical coding knowledge to claims decisions.
• Handling multiple claims and priorities in a deadline-driven setting.
• Working independently most of the day while aligning with team standards.
• Escalating issues or configuration concerns when needed.
• Maintaining accurate records in claims processing systems.

Skills

Claims processing

Medical coding

Independent decision making

Communication

Education

High School diploma or GED

Tools

HealthRules Payer

Microsoft Office

Job description

WE'RE HIRING | HEALTHCARE CLAIMS ADJUSTOR | U.S. HEALTH BENEFITS ADMINISTRATION

HEYA Solutions South Africa is looking for an experienced Healthcare Claims Adjustor to join our growing healthcare support team.

This role is for someone who already understands U.S. healthcare claims processing, medical coding, benefit plan administration, and who is ready to support a U.S.-based health benefits administrator working with self-funded employer groups.

WHAT YOU'LL DO

• Reviewing and assessing incoming healthcare claims for accuracy and completeness
• Adjudicating claims and processing payment to providers in line with Benefit Plan rules
• Working closely with the Claims Supervisor, Account Managers, System Configuration, and Quality Assurance teams
• Ensuring claims are processed accurately and within required turnaround times
• Applying knowledge of medical coding and benefit plan rules to claims decisions
• Managing multiple claims and priorities in a fast-paced, deadline-driven environment
• Working independently for the majority of the day while staying aligned with team standards
• Escalating and flagging issues, discrepancies, or system configuration concerns where needed
• Maintaining accurate records within proprietary claims processing systems

WHO WE'RE LOOKING FOR:

• Experience with claims processing systems is required; HealthRules Payer experience is strongly preferred.
• Knowledge of healthcare claims, medical coding, and Benefit Plan rules.
• Strong critical thinking skills and the ability to make sound, independent decisions.
• Excellent written and verbal communication skills.
• Ability to manage multiple issues at once within a fast-paced environment with production schedules and deadlines.
• Comfortable working independently for most of the day.
• Proficiency in Microsoft Office and web-based software, with the ability to learn proprietary computer systems.
• High School diploma or GED required.

If you understand U.S. healthcare claims and are looking for an opportunity to become part of an international healthcare operation, we'd be excited to hear from you and explore the next steps.

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