Senior Claims Administrator

Ambledown Financial Services; Gauteng; On-site; ZAR 250 000 - 350 000; Full time

Job summary

A healthcare solutions provider in South Africa is seeking a Senior Claims Administrator with strong clinical skills. The role includes authorising claim assessments, conducting clinical reviews, and addressing complex inquiries. Ideal candidates will possess a diploma or degree in nursing, experience in health insurance claims, and excellent communication abilities. This position requires attention to detail and the ability to function independently in a fast-paced environment.

Qualifications

• At least 2-3 years' gap cover claims experience.
• SANC Registered.
• FAIS Compliant (advantageous).
• Strong computer skills, including Microsoft Office and intermediate to advanced Excel.
• Excellent customer service, communication, and interpersonal skills.

Responsibilities

• Authorise assessed claims according to policy rules.
• Conduct clinical review and validation of claims.
• Respond to complex clinical queries.
• Maintain accurate records and documentation of claims assessments.

Skills

Customer service

Analytical skills

Attention to detail

Communication

Education

Clinical or Nursing Diploma/Degree

Tools

Microsoft Office

Excel

Job description

Introduction

We are seeking a Senior Claims Administrator with strong clinical background to join our team.

Duties & Responsibilities

• Authorise assessed claims in accordance with policy rules, benefits, and conditions.
• Conduct clinical review and validation of pre‑existing conditions and casualty claims.
• Attend to escalated and complex clinical queries.
• Respond to broker and policyholder queries in a timely and professional manner.
• Ensure compliance with internal policies, procedures, and regulatory requirements.
• Maintain accurate records and documentation of claims assessments and outcomes.
• Contribute to process improvement initiatives within the claims department.
• Any other duties as assigned by the company from time to time.
• The company reserves the right to change this job description at its sole discretion from time to time.

Minimum Requirements

• Clinical or Nursing Diploma / Degree.
• SANC Registered.
• FAIS Compliant (advantageous).
• At least 2 – 3 years' gap cover claims experience.
• Technical knowledge of various health insurance products.
• Advanced knowledge of ICD Codes, medical procedures, and medical aid schemes.
• Sound understanding of Prescribed Minimum Benefits (PMB) legislation in conjunction with gap cover.
• Experience in dealing with escalated and/or complex claims.
• Strong computer skills, including Microsoft Office and intermediate to advanced Excel.
• Excellent customer service, communication, and interpersonal skills.
• Advanced Business English (written and verbal).
• Strong attention to detail and accuracy.
• Analytical and problem‑solving skills with the ability to interpret clinical information.
• Ability to take ownership and responsibility for actions and outcomes.
• Ability to handle pressure while remaining calm, professional, courteous, and solution‑oriented.
• Ability to work independently and as part of a team.
• Ability to prioritise tasks effectively in a fast‑paced environment.
• Strong organisational and time‑management skills.
• Sound ethical judgment and integrity, ensuring compliance with internal policies and regulatory standards.
• Demonstrate continuous learning mindset with a willingness to stay current on clinical advancements and industry changes.