Senior Claims Administrator

Ambledown Financial Services; Johannesburg; On-site; ZAR 300 000 - 500 000; Full time

Job summary

A financial services company in Johannesburg is seeking a Senior Claims Administrator with a strong clinical background. The role involves authorising claims, conducting clinical reviews, and ensuring compliance with regulations. Candidates should have a Clinical or Nursing Diploma, be SANC registered, and possess 2-3 years of experience in gap cover claims. Strong attention to detail and excellent customer service skills are crucial for this position.

Qualifications

• Clinical or Nursing Diploma / Degree required.
• SANC Registration necessary.
• FAIS Compliance is advantageous.
• Strong attention to detail and accuracy is essential.

Responsibilities

• Authorise assessed claims according to policy rules.
• Conduct clinical review of pre-existing conditions.
• Respond to broker and policyholder queries professionally.
• Contribute to process improvement initiatives.

Skills

2 – 3 years' gap cover claims experience

Technical knowledge of health insurance products

Advanced knowledge of ICD Codes

Excellent customer service skills

Strong attention to detail

Analytical and problem-solving skills

Strong organisational skills

Education

Clinical or Nursing Diploma / Degree

SANC Registration

Tools

Microsoft Office

Excel (intermediate to advanced)

Job description

We are seeking aSenior Claims Administratorwith strong clinical background to join our team.

Qualifications

• Clinical or Nursing Diploma / Degree.
• SANC Registered.
• FAIS Compliant (advantageous).

Skills and Experience

• 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.

Reporting To

Claims Supervisor

Scope of Responsibility

• 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.

Changes

The company reserves the right to change this job description at its sole discretion from time to time.

Applications

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