Claims Assessor (Admed) Mmh250604-3

Role Purpose : To process medical expense shortfall (gap cover) claims in accordance with stipulated service levels and the terms and conditions of cover as defined in the policy wording.

Requirements : Matric / Grade 12

Basic medical qualification an advantage (e.g., nursing or similar qualification)

FAIS Fit and Proper including RE5

At least 2 years medical aid or gap cover claims processing and assessing experience

At least 1 year insurance experience

Basic knowledge of the local health and medical schemes industry, as well as an awareness of demarcation and legislation governing the local health industry.

Duties and Responsibilities :

Receive new claims via email and accurately pre-capture them, including updating members' personal details, onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.

Receive new Seamless claims via secured sites, importing them into the system – including updating members' personal details – onto the claims administration system (OWLS) within 24 hours.

Ensure claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with SLA's.

Interact with customers telephonically or via email regarding outstanding information or claims documentation on the same day or within 24 hours of receiving or capturing the claim.

Accurately capture clinical details of a claim on the claims administration system (OWLS) within 2 working days of receipt.

Prioritize claims where outstanding documentation has been received, ensuring these are captured within 48 hours.

Assess claims according to practice guidelines, policy wording, and protocols.

Finalize and forward claims to the quality assurance team for approval or rejection.

Ensure prompt handling and feedback on claims.

Respond to capture queries within 48 hours.

Detect and act on potential fraudulent claims.

Maintain high service levels when liaising with customers, intermediaries, binder holders, and colleagues.

Support the front-line team for inbound call overflows, query handling, complaints, and mailbox coordination.

Deliver on the principles of Treating Customers Fairly (TCF), focusing on Outcome 6.

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