Job Description

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.
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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.

• 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 the updating of members' personal details - onto the claims administration system (OWLS) on the same day or within 24 hours of receipt.
• Ensure claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed 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 the clinical details of a claim on the claims administration system (OWLS) on the same day or within 2 working days of receipt.
• Prioritise claims where outstanding documentation has been received, ensuring these documents are captured within 48 hours of receipt.
• Assess claims in accordance with 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 of receipt.
• Detect and act on potential fraudulent claims.
• Maintain a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, and colleagues.
• Provide support to the front-line team for inbound call overflows, query handling, complaints handling, and mailbox coordination when requested.
• Ensure the principles of Treating Customers Fairly (TCF) are delivered across all functions, with a specific focus on achieving TCF Outcome 6 (ensuring customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim, or make a complaint).

• Results and solutions driven.
• Strong focus on client centricity and service excellence.
• Strong problem-solving and decision-making capabilities.
• Organized and focused.
• Analytical skills with attention to detail.
• Resilient and able to work under pressure.
• Adaptable and self-disciplined.
• Good communication skills and the ability to professionally manage customers.
• Disciplined and reliable.
• A team player.
• Computer Literacy (MS Word, Outlook and Excel).
• Willing to go beyond the normal working day to achieve target service levels