Medical Claims Specialist - Escalations & Quality

Momentum; Sandton; On-site; ZAR 180,000 - 260,000; Full time

Job summary

Momentum in Johannesburg/Sandton seeks an experienced medical aid claims administrator to lead resolution of escalated queries and ensure accurate, timely processing of claims in line with policy rules.

You will assess claims, coordinate investigations on complex cases, provide updates to clients and stakeholders, and maintain high service levels while upholding compliance with industry regulations.

Qualifications

• Matric/grade 12 or equivalent.
• Computer literacy is essential for daily tasks.
• Comprehensive knowledge of medical aid assessing.
• Experience with Oracle is advantageous.
• Knowledge of legislation and industry regulations.
• Knowledge of claims assessment process (paper/EDI).
• Familiarity with relevant scheme/product rules.
• Experience with operating systems and claim processing tools.
• 3–5 years in medical aid claims administration or related work.
• Exposure to the insurance industry is preferred.

Responsibilities

• Review submitted claims to ensure accuracy and completeness.
• Process incoming claims within the defined service levels.
• Evaluate and process claims and payments as per standards.
• Identify and reject duplicate claims to prevent overpayment.
• Coordinate investigations on complex claims and make informed decisions.
• Assist clients and internal stakeholders with queries on claims.
• Conduct quality control checks to minimize errors in processing.
• Escalate queries requiring further investigation and provide feedback.
• Generate reports and update clients on claim status.
• Provide clear reasons for rejecting claims based on investigations.

Skills

Computer literacy

Medical aid claims knowledge

Claims processing knowledge

Education

Matric

Tools

Oracle platform

Operating systems

EDI systems

Job description

Momentum in Johannesburg/Sandton seeks an experienced medical aid claims administrator to lead resolution of escalated queries and ensure accurate, timely processing of claims in line with policy rules.

You will assess claims, coordinate investigations on complex cases, provide updates to clients and stakeholders, and maintain high service levels while upholding compliance with industry regulations.