Medical Aid Claims Administrator

Placements24; Centurion; On-site; ZAR 180,000 - 300,000; Full time

Benefits offered by this job

Competitive salary

Medical aid scheme membership

Provident fund contribution

Generous leave

Internal training and career growth

Structured work environment

Exposure to diverse medical claims

Supportive team culture

Job summary

Placements24 is seeking a meticulous Medical Aid Claims Administrator in Centurion to join a premier insurance team. The role focuses on accurate processing and adjudication of medical aid claims, verifying policy details, and ensuring timely resolution of queries.

Ideal candidates will have a solid grasp of ICD-10 and CPT coding, strong administrative skills, and a willingness to work in a fast-paced environment. Centurion-based position with growth opportunities in the insurance sector.

Qualifications

• Matric certificate (Grade 12) is essential; qualification in Medical Terminology or Health Sciences advantageous.
• Minimum of 3 years' experience processing medical aid claims.
• Thorough understanding of ICD-10 and CPT coding and medical terminology.
• Proficiency with medical claims processing software and MS Office.
• Excellent administrative and organizational skills with high accuracy.
• Strong communication and interpersonal skills.
• Based in Centurion or willing to commute daily.

Responsibilities

• Process and adjudicate a high volume of medical aid claims accurately and efficiently, adhering to service level agreements.
• Verify membership details, policy benefits, and eligibility for claimed services.
• Interpret and apply medical aid scheme rules, benefit limits, and co-payment requirements.
• Identify and investigate discrepancies or potential fraudulent claims, escalating as necessary.
• Communicate with healthcare providers to obtain necessary documentation or clarify claim details.
• Respond to member and broker queries regarding claims status, benefits, and outstanding accounts via phone and email.
• Ensure all claim data is captured accurately on the claims system for reporting and auditing purposes.
• Process pre-authorizations and referrals in line with scheme rules.
• Liaise with the finance department for payments and rejections.
• Stay updated on changes in medical aid regulations, coding, and scheme rules.

Skills

Attention to detail

Communication skills

Organization

Problem solving

Education

Matric (Grade 12)

Medical Terminology/Health Sciences qualification

Tools

Medical claims processing software

MS Office Suite

Job description

About the Role

Our client, a prominent name in the insurance industry, is actively seeking a meticulous and efficient Medical Aid Claims Administrator to join their dedicated team in Centurion, Gauteng. This role is critical for processing and managing medical aid claims accurately and promptly, ensuring that policyholders receive the benefits they are entitled to. The successful candidate will be responsible for verifying policy details, adjudicating claims against benefit schedules, and liaising with healthcare providers and members to resolve queries. A strong understanding of medical terminology, diagnostic codes (ICD-10), and procedural codes (CPT) is essential. This position requires an individual with exceptional attention to detail, excellent administrative skills, and a commitment to providing outstanding service in the Centurion branch. You will be part of a supportive team environment that values accuracy and efficiency in handling sensitive claim information within the insurance landscape.

Key Responsibilities

• Process and adjudicate a high volume of medical aid claims accurately and efficiently, adhering to service level agreements.
• Verify membership details, policy benefits, and eligibility for claimed services.
• Interpret and apply medical aid scheme rules, benefit limits, and co-payment requirements.
• Identify and investigate discrepancies or potential fraudulent claims, escalating as necessary.
• Communicate with healthcare providers (doctors, hospitals, pharmacies) to obtain necessary documentation or clarify claim details.
• Respond to member and broker queries regarding claims status, benefits, and outstanding accounts via phone and email.
• Ensure all claim data is captured accurately on the claims system for reporting and auditing purposes.
• Process pre-authorizations and referrals in line with scheme rules.
• Liaise with the finance department for payments and rejections.
• Stay updated on changes in medical aid regulations, coding, and scheme rules.

Requirements

• Matric certificate (Grade 12) is essential; a relevant qualification in Medical Terminology or Health Sciences is advantageous.
• Minimum of 3 years of experience in processing medical aid claims, preferably within a medical aid administrator or insurer.
• Thorough understanding of medical coding (ICD-10, CPT) and medical terminology.
• Proficiency in using medical claims processing software and MS Office Suite.
• Excellent administrative and organizational skills with a high level of accuracy.
• Strong communication and interpersonal skills to handle queries effectively.
• Ability to work under pressure and manage multiple tasks simultaneously.
• Adept at problem-solving and making sound decisions regarding claim adjudication.
• Knowledge of different medical aid plans and their respective benefits.
• Must be based in or willing to commute daily to Centurion, Gauteng.

Benefits

• Competitive monthly salary and potential for annual performance bonuses.
• Membership in a comprehensive medical aid scheme.
• Contribution to a provident fund.
• Generous annual leave and paid time off.
• Opportunities for internal training and career progression within the insurance field.
• A professional and structured work environment in Centurion.
• Exposure to a wide range of medical claims and healthcare providers.
• Supportive team culture focused on collective success.