Job Purpose

To ensure that all electronic and physical claims and correspondence received in the business are routed timeously to all levels within the organisation, for both internal and external stakeholders.

Key Responsibilities

• To ensure all claims are prepared in accordance with departmental standards, in order to ensure that claims are processed accordingly
• To ensure that all claims have valid member / provider details and are placed in batches
• To scan all claim and correspondence batches and route to the relevant department.
• To ensure that all enquiries from both internal and external customers are investigated and resolved within the SLA and to provide either written or verbal feedback to the relevant stakeholder.
• To compile reports, utilising Excel, based on claims received.
• To verify member and provider details and source outstanding information, in order to enable accurate and swift processing of claims.
• To liaise with providers confirming cover and benefits, where necessary

CUSTOMERS / STAKEHOLDERS

Internal

• Operations team
• Finance Team
• Member Care

External

• Members
• 3rd Party Service Providers

DECISIONS

Decisions as outlined by the scope of role and responsibilities in line with the rules and regulations of the medical scheme.

TIME HORIZON

Short Term

KNOWLEDGE

Knowledge

• Understanding of tariff guides and product rules (medical tariff structure) - Intermediate
• (Operating) system - Intermediate
• Risk Awareness - Intermediate
• Process understanding - Intermediate
• Health Insurance / Medical aid Industry - Intermediate

SKILLS

• Attention to detail - Intermediate
• Computer Literacy (basic) and MS Office - Intermediate
• Written and verbal communication skills - Basic
• Root cause analysis and problem solving - Intermediate
• Analytical thinking - Basic

EDUCATION

• Diploma (Minimum) - Essential
• Relevant business certificate - Advantageous

EXPERIENCE

• Claims assessing (Health / Insurance) - 2 – 3 Years - Essential
• General administration /data capturing (Health / Insurance) - 2 – 3 Years - Advantageous

BEHAVIOURAL COMPETENCIES

Behavioural success factors that are either pertinent to the role or carried out on a daily basis. These are the observable behaviours or personal attributes (actions, verbal or non-verbal cues) that you would see on a daily basis. Please bear in mind that the 8 chosen are the most important behavioural attributes – the others as listed may well be relevant too although not as essential to daily operations

• To ensure all claims are prepared in accordance with departmental standards, in order to ensure that claims are processed accordingly
• To ensure that all claims have valid member / provider details and are placed in batches
• To scan all claim and correspondence batches and route to the relevant department.
• To ensure that all enquiries from both internal and external customers are investigated and resolved within the SLA and to provide either written or verbal feedback to the relevant stakeholder.
• To compile reports, utilising Excel, based on claims received.
• To verify member and provider details and source outstanding information, in order to enable accurate and swift processing of claims.
• To liaise with providers confirming cover and benefits, where necessary

• Attention to detail - Intermediate
• Computer Literacy (basic) and MS Office - Intermediate
• Written and verbal communication skills - Basic
• Root cause analysis and problem solving - Intermediate
• Analytical thinking - Basic

• Diploma (Minimum) - Essential
• Relevant business certificate - Advantageous