To lead the resolution of high-level and escalated queries, retain the current membership base, and take responsibility for the quality, timely delivery, and appropriateness of the team's recommendation.
Requirements
- Matric
- Computer literate.
- Comprehensive knowledge of all aspects of medical aid assessing is essential.
- Working on the Oracle platform is an advantage.
- Knowledge of relevant legislation and industry regulations
- Knowledge of the claims assessment process (e.g., paper and EDI)
- Knowledge of the relevant scheme or product rules
- Knowledge of relevant operating systems and tools
- 3 - 5 years medical aid claims administration or related experience
- Exposure to the insurance industry (preferred)
PROCESS
- 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.
- Escalate queries requiring further investigation and provide timely feedback to clients.
- Generate reports and provide internal clients with updates on the status of claims.
- Provide clear reasons for rejecting claims based on investigations and contractual obligations.
- Offer authoritative expertise to clients and stakeholders regarding claims matters.
- Foster and maintain strong relationships with clients and internal and external stakeholders.
- Fulfill service level agreements with clients and stakeholders to effectively manage client expectations.
- Make recommendations for enhancing client service and ensuring fair treatment within the scope of responsibility.
- Actively participate in creating a culture that values relationships, encourages feedback, and delivers exceptional client service.
- Develop and maintain productive and collaborative relationships with peers and stakeholders.
- Actively contribute to and support change initiatives within the organization.
- Continuously enhance professional expertise in terms of industry knowledge, legislation, and best practices.
- Contribute to continuous innovation by sharing and implementing new ideas.
- Take ownership of career development and drive personal growth.
- Contribute to the financial planning process within the designated area.
- Identify opportunities to improve cost-effectiveness and operational efficiency.
- Manage financial and other resources under your control with diligence and responsibility.
- Provide input into risk identification processes and communicate recommendations in the appropriate forums.
