Medical Aid Claims Specialist — Centurion

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

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.