Claims Assessor (ADMED)
Location: Sandton, Gauteng, South Africa
Closing Date: 19 March 2025
Reference Number: MMH250304-4
Position Type: Permanent
Cluster: Guardrisk
Role Family: Client Services
Remote Opportunity: Some of the time
Introduction
To process medical expense shortfall (gap cover) claims according to service levels and policy terms and conditions.
Role Purpose
Ensure accurate and efficient processing of medical expense shortfall claims in line with policy guidelines.
Requirements
- Matric / Grade 12
- Basic medical qualification (advantageous)
- Computer literacy (MS Word, Outlook, and Excel)
- FAIS Fit and Proper, including RE5
- Minimum 2 years' experience in medical aid or gap cover claims assessing
- Minimum 1 year insurance experience
- Knowledge of the local health and medical schemes industry
- Awareness of demarcation and health legislation
Duties & Responsibilities
- Pre-capture new claims and update members’ personal details on the OWLS system within 24 hours of receipt
- Import Seamless claims into the OWLS system within 24 hours
- Verify claims data from medical schemes according to SLA requirements
- Contact clients regarding outstanding documents within 24 hours of claim receipt
- Capture clinical claim details on the system within 2 working days
- Prioritise claims with received outstanding documents within 48 hours
- Assess claims according to policy wording and protocols
- Submit claims to the quality assurance team for approval or rejection
- Respond to capture queries within 48 hours
- Detect and report potential fraudulent claims
- Provide high-level service to clients, intermediaries, and colleagues
- Support inbound call overflows, complaints handling, and mailbox coordination
- Apply Treating Customers Fairly (TCF) principles, especially Outcome 6
Competencies
- Client service excellence
- Problem-solving and decision-making skills
- Strong attention to detail
- Good communication skills
- Resilient under pressure
- Team player
- Computer literate
- Reliable and self-disciplined
- Willingness to work beyond normal hours when needed
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