Consultant: Claims Management

Gauteng, Full Time

Job  Summary    
To analyze, reconcile, process information on a Claims account. To assess various type of claims submitted electronically / paper or received via fax or e-mail.  Assessing must meet both quality and quantity set standards.  To do corrections on accounts as requested by other departments or the Scheme.  To complete Reversals as requested by Internal Clients or any other third parties.
Minimum Requirements    

Grade 12
Tertiary Qualification


Medical Scheme Administration Experience 2 years essential
Assessing experience 2 years plus essential
Extensive understanding of the Administration System essential
Knowledge of Reference Price List essential
In-depth knowledge of Medical Scheme Rules essential
MS Office
Medical Scheme Act essential
Knowledge of Medical Aid Legislation and regulations essential
Knowledge of ICD 10 codes essential
Knowledge of PMB legislation essential

Duties and Responsibilities    

Reconcile member or provider claims received.
Accurate daily assessing of targets.
Manage quality error percentage.
Ensure consistent and excellent application of set standards and Scheme Rules.
Excellent administrative skills e.g. daily record keeping.
Escalate requests for corrections to relevant Consultant.
Follow up and resolve routed enquiries.
Good Communication
Good administration skill’s, including record keeping and the ability to work under pressure
Must maintain a high level of productivity to asses claims daily targets set
High attention to detail in order to identify system risks or process shortfalls
Must be quality aware and quantity orientated
Operating System knowledge
Excellent time management in order to manage deadlines
Excellent in query resolution

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