Talent Pool: Query Resolution Officer MMH261030-3

Momentum; Cape Town; On-site; ZAR 167,000 - 279,000; Full time

Job summary

Momentum in Cape Town is seeking an experienced Medical Aid Claims Assessor to resolve escalated queries with accuracy and timeliness. You will review claims, apply PMB rules, and coordinate with internal teams to maintain service levels.

Join a detail‑oriented team where you will interpret scheme rules, use EDI and workflow systems, and contribute to a high‑performance culture. The role requires Matric and at least 2 years of relevant claims experience.

Qualifications

• Matric/Grade 12 - essential.
• Minimum 2 years of Medical Aid Claims Assessing experience - essential.
• Proven experience in assessing Medical Aid claims (paper and/or EDI) - essential.
• Excellent literacy, numeracy and communication skills.
• Knowledge of PMB and SAMA/NHRPL tariffs.
• Good knowledge of modifiers and their application.
• Computer literacy (Email, Word, Excel).
• Ability to interpret and apply scheme rules correctly.
• Passionate about driving a high performance culture.

Responsibilities

• Accurate and timely resolution of claims queries.
• Correctly reverse and reprocess related claims.
• Ensure no duplicate claims are paid during processing.
• Apply appropriate pay codes.
• Assist other departments with claims-related queries.
• Liaise with other departments to resolve queries.
• Record all queries and interactions in the workflow system.
• Deliver high quality service output.

Skills

Medical aid claims

Claims assessment experience

Communication skills

Literacy & numeracy

PMB knowledge

Modifiers knowledge

Computer literacy

Scheme rules interpretation

NHRPL/SAMA tariffs knowledge

High performance culture

Education

Matric/Grade 12

Tools

EDI claims processing

Workflow system

Job description

Role Purpose

To ensure a professional and consistent customer service delivery through the resolution of escalated Medical Aid queries.

Requirements

• Matric/ Grade 12 - essential
• Minimum 2 years of Medical Aid Claims Assessing experience - essential
• Proven experience in the assessing of Medical Aid claims (paper and/or EDI) - essential
• Excellent literacy, numeracy and communication skill
• Multi discipline claims knowledge
• Good knowledge of PMB at industry level as well as in house PMB processes
• Good knowledge of modifiers and their application
• Computer literacy (especially Email, Word and Excel)
• Passionate about driving a high performance culture
• The ability to interpret and apply scheme rules correctly
• Knowledge of the NHRPL- National Health Reference Price List (Previously Known as BHF) and SAMA Tariffs

Duties and Responsibilities

• Accurate and timeous resolution of Claims Queries
• Correctly reverse and reprocess the related claim
• Ensuring that no duplicate claims are paid during the process
• Appropriate pay code is applied
• Assisting other departments with claims related queries
• Liaising with other departments to resolve queries
• Recording all queries and interactions with customers onto the workflow system.
• High quality and service output