PMB Specialist

A key summary of the role is outlined below.  A more comprehensive job specification with full details is available after initial contact and a successful CV review.

Duties / Key Responsibilities

• Take ownership of PMB claims once they have been identified for specialist review.
• Complete and submit PMB applications and scheme-specific supporting documents.
• Assess whether claims meet PMB requirements and return non-qualifying cases to the relevant administrator.
• Work with surgeons and other healthcare providers to obtain clinical notes, ICD-10 codes and supporting information.
• Track scheme turnaround times and follow up promptly when review periods expire.
• Investigate payment differences and challenge incorrect PMB rejections or funding decisions.
• Escalate unresolved matters through the appropriate medical scheme channels, including Principal Officers where required.
• Prepare and manage formal complaints to the Council for Medical Schemes when PMB obligations are not being met.

Requirements

• 2–3 years' relevant healthcare or medical claims industry experience.
• Strong working knowledge of the PMB process.
• Good computer literacy, numeracy and typing skills.
• Able to prepare clear claim information for medical scheme queries and regulatory escalations.
• Strong analytical and problem-solving ability.
• Excellent attention to detail.
• Comfortable challenging medical scheme decisions and following matters through to resolution.

Education

• Matric is required.
• A relevant administrative qualification would be advantageous.

Soft Skills

• Strong ownership mindset with the drive to see issues through.
• Clear, confident communicator with a client-focused approach.
• Resilient and tenacious when dealing with difficult claims or rejected submissions.
• Able to work independently while contributing well within a team.
• Comfortable following structured processes while also spotting opportunities to improve them.
• Adaptable, curious and keen to keep learning as the role and team continue to evolve.

Salary