Medical Claims Assessor, Sandton

SUMMARY:
Medical Claims Assessor, Sandton

POSITION INFO:

One of our large clients, a Medical Scheme Administrator, based in Sandton, is currently looking for a Claims Assessor to start as soon as possible, or immediately!

JOB PURPOSE:

To assess and capture paper and electronic claims in accordance with guidelines, Scheme Rules and Protocols.

Minimum requirements:

• Matric
• Minimum 5 years data capturing experience in a Medical Environment
• Outgoing, professional and presentable
• Motivated, independent and energetic

Duties include, but are not limited to:

• Receives and captures paper claims

-       Receives batched claims from batch controller on a daily basis

-       Pre-Assessing of claims on an all disciplines and schemes

-       Reviews dependant history in accordance with Guidelines and Protocols

-       Updates the batch control form ensuring 100% accuracy of captured data

-       Captures member number, practice number, dependant code, date of service, tariff code, modifier, R-value and multipliers onto the system ensuring 100% accuracy of the captured data

-       Checks as per system requirements for pre-authorizations

-       Capturing of member payments where receipts and credit card payments are attached

-       Allocates required benefit in accordance with protocols / grids / HOC

• Reviews and actions paper claims:

-       Reviews additional screens in order to source specific rejection codes

-       Rejects the specific tariff code with the specific reject code in accordance with Guidelines and Protocols

-       Updates the departmental batch control form ensuring 100% accuracy

-       Forwards the completed batch to the Quality Controller for quality controlling purposes

-       Forwards the batch control form to the Team Leader for pre-assessing verification

• Reviews and actions electronic claims:

-       Print original EDI from an outstanding excel report send to the assessor

-       Review against the electronic claim to ensure 100% accuracy of data received

-       Reviews additional screens in order to source specific rejection codes / HOC / hospital pre-auth

Rejects the specific tariff code with specific reject code in accordance with Guidelines and Protocols

Please note: Only shortlisted candidates will be contacted.

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