To process medical expense shortfall (gap cover) claims in accordance with stipulated service levels and the terms and conditions of cover as defined in the policy wording.
Requirements
- Matric /Grade 12
- Basic medical qualification an advantage (e.g. nursing or similar qualification)
- FAIS Fit and Proper including RE5
- At least 2 years medical aid or gap cover claims processing and assessing experience
- At least 1 year insurance experience
- Basic knowledge of the local health and medical schemes industry, as well as an awareness of demarcation and legislation governing the local health industry.
- Receive new claims via email and accurately pre-capture them, including updating members personal details, onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.
- Receive new Seamless claims via Secured sites, importing them into the system including the updating of members personal details onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.
- Ensure claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed SLAs.
- Interact with customers telephonically or via email regarding outstanding information or claims documentation on the same day or within 24 hours of receiving or capturing the claim.
- Accurately capture the clinical details of a claim on the claims administration system (OWLS) on the same day or within 2 working days of receipt.
- Prioritise claims where outstanding documentation has been received, ensuring these documents are captured within 48 hours of receipt.
- Assess claims in accordance with practice guidelines, policy wording, and protocols.
- Finalize and forward claims to the quality assurance team for approval or rejection.
- Ensure prompt handling and feedback on claims.
- Respond to capture queries within 48 hours of receipt.
- Detect and act on potential fraudulent claims.
- Maintain a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, and colleagues.
- Provide support to the front-line team for inbound call overflows, query handling, complaints handling, and mailbox coordination when requested.
- Ensure the principles of Treating Customers Fairly (TCF) are delivered across all functions, with a specific focus on achieving TCF Outcome 6 (ensuring customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim, or make a complaint).
