Description:
CLAIMS ASSESSOR (Gap Cover"Position Purpose:
To ensure that all paper Gap claims are accurately captured into the iMed system
Experience:
3 years relevant healthcare industry, short term insurance and credit data capturing and claims processing experience
Qualifications:
Matric and RE5 Required
Accountabilities:
Client service delivery and quality:
- Follow procedures and cooperate with peers and leader for best possible service delivery
- Defined legal, statutory and regulatory compliance is maintained at the required standards
- Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary
- Contribute to cost savings within the department to assist with financial goals and targets
- Conduct accurate and effective intervention/reconciliation of administration on all allocated claims
- Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement
- Continuously apply relevant rules
- Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims
- Rectify incorrect information on claims and escalate where required
- Reconcile claims where required and communicate outcome
- Ensure correct payments to vendor or member
- Meet delivery objectives through working with other team members within and linked to the department/project
- Resolve operational performance variations and problems and escalate unresolved issues to higher levels
- Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery
Operational Implementation of Strategy:
- Keep up to date with operational changes implemented in response to important external influences
- Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
- Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement
- Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives.
- Engage in development, coaching and mentoring.
- Support transformation through valuing diversity.
- Behave in alignment with the Afrocentric values.
- Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies.
- Identify, investigate, respond to and refer IT assessing queries appropriately.
- Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved.
- Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in.
- Duplicate check claims received, and process claims and emails according to processes.
- Capture all claims received in accordance with relevant legislation and processes.
- Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes.
- Providing coding review and resolution on call centre queries.
- Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes.
- Communicate with Stake holders.
- Maintain clinical documents and processes.
- Review and action QA reports and provide corrective action.
- Assist with training and sharing of knowledge within the team and clients.
- Assist on the various Call centres.
- Assist with call centre call backs.
- Review and assess gap claims.
- Verify documentation and ensure all required information is completed.
- Communicate with clients and stakeholders to gather necessary information.
- Process claims efficiently and accurately.
- Maintain detailed records of claims and assessments.
- Collaborate with other departments.
- Assist with departmental Adhoc duties where required.
Position Specific Outputs 2
Competency Requirements
Knowledge:
- Knowledge and application of relevant legislation.
- Knowledge and application of processes and procedures.
- Knowledge of scheme rules and contractual negotiations.
Skills:
- Problem solving and decision making skills
- Business Writing Skills
- Communication Skills
- Computer Technology Skills
- Task Management
- Adobe Creative Suite
- Data modelling and evaluation
- Attention to Accuracy and Detail
- Numerical Ability
- Customer Focus
- Multitasking
- Strong analytical and problem solving skills
- Proficiency in Microsoft Office Suite
- Relevant systems knowledge and applicatio
Requirements:
- Follow procedures and cooperate with peers and leader for best possible service delivery
- Defined legal, statutory and regulatory compliance is maintained at the required standards
- Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary
- Contribute to cost savings within the department to assist with financial goals and targets
- Conduct accurate and effective intervention/reconciliation of administration on all allocated claims
- Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement
- Continuously apply relevant rules
- Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims
- Rectify incorrect information on claims and escalate where required
- Reconcile claims where required and communicate outcome
- Ensure correct payments to vendor or member
- Meet delivery objectives through working with other team members within and linked to the department/project
- Resolve operational performance variations and problems and escalate unresolved issues to higher levels
- Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery
- Keep up to date with operational changes implemented in response to important external influences
- Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
- Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement
- Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives.
- Engage in development, coaching and mentoring.
- Support transformation through valuing diversity.
- Behave in alignment with the Afrocentric values.
- Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies.
- Identify, investigate, respond to and refer IT assessing queries appropriately.
- Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved.
- Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in.
- Duplicate check claims received, and process claims and emails according to processes.
- Capture all claims received in accordance with relevant legislation and processes.
- Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes.
- Providing coding review and resolution on call centre queries.
- Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes.
- Communicate with Stake holders.
- Maintain clinical documents and processes.
- Review and action QA reports and provide corrective action.
- Assist with training and sharing of knowledge within the team and clients.
- Assist on the various Call centres.
- Assist with call centre call backs.
- Review and assess gap claims.
- Verify documentation and ensure all required information is completed.
- Communicate with clients and stakeholders to gather necessary information.
- Process claims efficiently and accurately.
- Maintain detailed records of claims and assessments.
- Collaborate with other departments.
- Assist with departmental Adhoc duties where required.
- Knowledge and application of relevant legislation.
- Knowledge and application of processes and procedures.
- Knowledge of scheme rules and contractual negotiations.
- Problem solving and decision making skills
- Business Writing Skills
- Communication Skills
- Computer Technology Skills
- Task Management
- Adobe Creative Suite
- Data modelling and evaluation
- Attention to Accuracy and Detail
- Numerical Ability
- Customer Focus
- Multitasking
- Strong analytical and problem solving skills
- Proficiency in Microsoft Office Suite
- Relevant systems knowledge and applicatio
02 Jun 2025;
from:
careers24.com