Claims Quality Assessor (ADMED)
Location: Sandton, Gauteng, South Africa
Closing Date: 19 March 2025
Reference Number: MMH250304-5
Position Type: Permanent
Cluster: Guardrisk
Role Family: Sales
Remote Opportunity: Some of the time
Introduction
As a Claims Quality Assessor in the Admed department, your role is to assess the quality of all claims processed by the Admed claims assessors, ensuring accuracy, completeness, and validity.
Role Purpose
To assess the quality of claims processed by the Admed claims team and ensure compliance with company guidelines and regulations.
Requirements
- Matric / Grade 12
- Basic medical qualification (advantageous)
- MS Office proficiency
- Minimum 3 years’ experience in medical aid or gap cover claims processing and assessing
- Minimum 2 years’ insurance experience
- Knowledge of the local health and medical schemes industry
- Understanding of demarcation and legislation in the health industry
Duties & Responsibilities
- Assess claims allocated through the OWLS system for accuracy and completeness
- Investigate claims flagged as possible pre-existing conditions within 2 working days
- Maintain detailed pre-existing condition registers
- Quality assess claims returned from external service providers
- Return claims to assessors with correct error reasons
- Finalise quality-assured claims for approval or rejection
- Detect and report potential fraudulent claims
- Review clinical details of claims within 2 working days
- Ensure claims align with policy wording, practice guidelines, and protocols
- Liaise with clients, intermediaries, and binder holders
- Prepare weekly and monthly reports for the Quality Assurance Manager
- Uphold Treating Customers Fairly (TCF) principles, particularly Outcome 6
Competencies
- Strong customer service orientation
- Excellent communication skills
- Analytical with attention to detail
- Resilient and able to work under pressure
- Self-driven and results-oriented
- Reliable with good time management skills
- Ability to work independently and in a team
- Computer literate and adaptable
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