Senior Medical Claims Resolution Specialist

Pivot Services; Sandton; On-site; ZAR 240,000 - 360,000; Full time

Job summary

Pivot Services in Sandton is seeking a Claims Administrator to lead the resolution of high-level and escalated queries, retain the current membership base, and ensure the quality, timeliness, and appropriateness of the team’s recommendations.

The role requires reviewing and processing medical aid claims with strict adherence to service levels and standards, and coordinating investigations on complex claims to support informed decision-making.

Qualifications

• years medical aid claims administration or related experience

Responsibilities

• Review submitted claims to ensure accuracy and completeness, facilitating the determination of compensation.
• Accurately process incoming claims within the defined service level agreement.
• Evaluate and process claims and payments according to predetermined standards and rules.
• Identify and reject duplicate claims to prevent duplication of compensation.
• Coordinate or conduct investigations on complex claims, make informed decisions based on findings, and approve or reject claims accordingly.
• Assist clients and internal stakeholders with queries related to claims.
• Conduct quality control checks to minimize error rates in claim processing.

Job description

Pivot Services in Sandton is seeking a Claims Administrator to lead the resolution of high-level and escalated queries, retain the current membership base, and ensure the quality, timeliness, and appropriateness of the team’s recommendations.

The role requires reviewing and processing medical aid claims with strict adherence to service levels and standards, and coordinating investigations on complex claims to support informed decision-making.