Talent Pool: Claims Administrator MMH251128-2

Momentum; Sandton; On-site; ZAR 180,000 - 240,000; Full time

Job summary

Momentum is hiring to review, process and manage benefit claims within service level agreements and company policies. The role requires 1–2 years of claims processing experience and knowledge of both paper-based and Electronic Data Interchange (EDI) systems.

You will collaborate with stakeholders, maintain records, and help enhance client claim experiences. Desirable qualifications include a bachelor’s degree in business administration, insurance, or finance, and training in scheme rules,

Qualifications

• 1–2 years of experience in claims processing or similar field.
• Experience assessing insurance/medical aid claims, with paper-based and electronic data proficiency.
• Familiarity with EDI methods and claims operating systems.

Responsibilities

• Process and assess disability, dread disease, income disability and other medically assessed claims.
• Collaborate with stakeholders to improve claims assessment and client experience.
• Maintain accurate records and ensure compliance with policies and regulations.
• Provide insights and testing support for claims systems development.

Skills

Claims processing

Disability/medical claims

EDI systems

Regulatory knowledge

Paper-based & electronic data

Claims systems proficiency

Client service

Reference to policies

Education

Grade 12 / National Senior Certificate

Bachelor's degree in business administration, insurance, finance

Tools

Claims management software

EDI tooling

Job description

Role Purpose

To effectively review, process and manage benefit claims within service level agreements and according to company policies and procedures.

Requirements

• National Senior Certificate / Grade 12 Certificate - (Essential)
• A bachelor's degree or equivalent qualification in a relevant field such as business administration, insurance, finance, or a related discipline - (Desirable).
• Scheme rules and regulations training - (Desirable)
• Benefits training - (Desirable)
• Claims training - (Desirable)
• 1-2 years of experience in claims processing or a similar field,
• Experience in assessing relevant insurance or medical aid claims, ideally with proficiency in both paper-based and Electronic Data
• Interchange (EDI) methods - (Desirable).
• A comprehensive understanding of the legal and regulatory frameworks governing claims administration (e.g., knowledge of insurance laws, data privacy regulations, claims handling guidelines, and any other applicable legislation).
• Knowledge in both traditional paper-based claims assessment processes and electronic data interchange (EDI) systems.
• Knowledge in utilising claims operating systems and tools (i.e, industry-standard claims management software, databases, and other technological tools used in processing and documenting claims).
• Familiarity with the specific scheme or product rules governing the claims being processed (e.g., understanding the coverage, exclusions, limitations, and other relevant provisions specific to the insurance product or scheme being administered).
• A basic understanding of medical terminology, conditions, and assessments related to the claims being processed.

Duties and Responsibilities

Process

• Process and assess disability, dread disease, income disability claims, and other medically assessed claims in accordance with service level agreements, ensuring accurate and efficient claim processing.
• Collaborate and partner with relevant stakeholders to enhance the claims assessment process and improve the client's claim experience.
• Advise on and contribute to the development of procedures and processes within the specialised area to drive continuous quality improvement and service enhancement in claims processing.
• Maintain accurate records of all assessed claims, aligning with business expectations and relevant legislation, to ensure comprehensive documentation and accountability.
• Stay updated on relevant regulatory frameworks, insurance-related court decisions, and determinations by regulatory bodies, ensuring compliance in claims processing and handling.
• Identify opportunities for continuous improvement, cost reduction, and quality enhancement in claims decisions, as well as system enhancements, to optimise overall efficiency.
• Provide insights, knowledge, assistance, and testing support as necessary for the development and maintenance of claims systems, aiming for improved quality, accuracy, and efficiency.
• Contribute to the review and alignment of claims policies, practices, forms, and documentation with risk management standards, product changes, and legislative updates, ensuring compliance and best practices.
• Deliver accurate and timely reporting, analysis, and insights on assessed claims, providing valuable information for decision-making and operational efficiency.

CLIENT

• Provide authoritative expertise to clients and stakeholders, offering professional guidance and support in claims assessment and processing.
• Build and cultivate strong relationships with clients, as well as internal and external stakeholders, fostering trust and effective collaboration.
• Ensure delivery on service level agreements made with clients and stakeholders, proactively managing client expectations and addressing any concerns or issues.
• Make recommendations to improve client service and ensure fair treatment of clients within your area of responsibility, striving for exceptional customer satisfaction.
• Actively participate in and contribute to a culture that fosters rewarding relationships, facilitates feedback, and provides exceptional client service, promoting a positive and customer-centric work environment.

PEOPLE

• Foster productive and collaborative working relationships with peers and stakeholders, promoting teamwork and knowledge sharing.
• Positively influence and actively participate in change initiatives, embracing and driving positive transformations in the workplace.
• Continuously develop professional expertise in terms of industry knowledge, legislation, and professional skills, staying abreast of advancements and best practices.
• Contribute to continuous innovation through the development, sharing, and implementation of new ideas, fostering a culture of creativity and improvement.
• Take ownership of driving personal career development, seeking opportunities for growth and learning to enhance professional capabilities.

FINANCE

• Contribute to the financial planning process within your area of responsibility, providing input and insights to support effective financial management.

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