U.S. Healthcare Claims Specialist – Adjudication & Coding

Heya South Africa; Johannesburg; On-site; ZAR 300,000 - 520,000; Full time

Job summary

Heya South Africa is seeking an experienced Healthcare Claims Adjustor to join our team in Johannesburg. You will handle U.S. healthcare claim processing, coding, and benefit-plan rules for a U.S.-based administrator, supporting self-funded employer groups.

You should understand claim processing systems (HealthRules Payer preferred), medical coding, and have strong communication and independent work skills in a fast-paced environment.

Qualifications

• Experience with claims processing systems required; HealthRules Payer preferred.
• Knowledge of healthcare claims, medical coding, and benefit plan rules.
• Strong critical thinking and independent decision making.
• Excellent written and verbal communication skills.
• Ability to manage multiple issues in a fast-paced environment with deadlines.
• Comfortable working independently for most of the day.
• Proficiency in Microsoft Office and web-based software; learn proprietary systems.
• High School diploma or GED required.

Responsibilities

• Reviewing and assessing incoming healthcare claims for accuracy and completeness.
• Adjudicating claims and processing payments to providers per plan rules.
• Collaborating with Claims Supervisor, Account Managers, and QA teams.
• Ensuring timely processing within turnaround targets.
• Applying medical coding knowledge to claims decisions.
• Handling multiple claims and priorities in a deadline-driven setting.
• Working independently most of the day while aligning with team standards.
• Escalating issues or configuration concerns when needed.
• Maintaining accurate records in claims processing systems.

Skills

Claims processing

Medical coding

Independent decision making

Communication

Education

High School diploma or GED

Tools

HealthRules Payer

Microsoft Office

Job description

Heya South Africa is seeking an experienced Healthcare Claims Adjustor to join our team in Johannesburg. You will handle U.S. healthcare claim processing, coding, and benefit-plan rules for a U.S.-based administrator, supporting self-funded employer groups.

You should understand claim processing systems (HealthRules Payer preferred), medical coding, and have strong communication and independent work skills in a fast-paced environment.