Claims Administrator

SUMMARY:
Claims administrator with experience in medical claims needed in the insurance sector.

POSITION INFO:

Responsibilities

• Validate and process claims according to policy conditions, benefit, and business rules, manually or electronically, for all practice types, i.e. general or dental practitioners, pathology, radiology, and hospital claims.

• Assist the Claims Supervisor with claims administration business rules, standard operational processes, claims improvement, as well as data quality management within the claims department.
• Assist with In-house training for new staff.
• Complete daily workflow processes within SLA.
• Effectively and professionally manage correspondence or claim queries received within SLA.
• Incorporating the principles of Treating Customers Fairly (TCF) in the claims process.
• Immediately refer suspicious or fraudulent claims to the Claims Supervisor or risk management department

Qualification & experience

• Matric
• FAIS Compliant (RE5 and Fais Qualification with at least 120 credits)
• At least 3-5 years’ experience in a similar role.
• Sound understanding of the South African Medical aid or Health insurance benefits and options.
• Experience in working on the MIP Administration System.
• Knowledge of ICD codes, RPL tariffs and medical procedures.
• Ability to liaise with external and internal parties.
• Ability to work within an established team.
• Excellent customer services, written and communication skills – strong business English.
• Excellent data entry and typing skills.
• Adaptable – fast learner and shows a positive response to change.
• Excellent analytical skills.
• Pays attention to detail.
• Takes ownership and responsibility.
• Excellent computer skills - MS Office a must with intermediate/advanced Excel skills.
• A good understanding of claims risk profiling.
• A good understanding of creating standard operating procedures
• Resilient: must be able to work under constant measurement and pressure and remain calm, professional, and willing to assist.
• Knowledge and understanding of how claim modifiers work.
• Knowledge and understanding of how service provider claims are assessed, i.e. paper and electronic claims.
• Good understanding of electronic claim submissions via switching houses and bureaus.

NB! This job is now closed. You can apply for other jobs by uploading your CV.