Job Description

Introduction

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

Disclaimer

As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose

To provide an effective and efficient service to clients by receiving, evaluating and responding to Medical Aid claims queries timeously.

Requirements

Qualifications

Matric (essential)
Relevant tertiary qualification (advantageous)
Claims School training (essential)

Experience

3 - 5 years in the medical aid industry (essential)
2 - 3 years Claims processing and query management experience within the medical aid industry (essential)

Knowledge

Understanding and knowledge of the interpretation and application of CMS, DoH, BHF, Private hospitals, etc

Duties & Responsibilities

Process

Identifying risks and possible anomalies to the company and escalate accordingly.
Maintaining a consistent service delivery to ensure client retention and satisfaction.
Ensuring Service Level Agreements are met and exceeded at all times.
Providing first time resolution on queries of a complex nature.
Dealing promptly with client requests in a competent, efficient and professional manner.
Driving and supporting effective teamwork within the department.
Engaging in appropriate training interventions to promote own professional development.
Recording of all queries and interactions with customers onto the workflow and reflection systems.
Liaise with the Clinical Advisors i.e. Medical Advisors, Radiologist, Pathology accordingly.
Collaborate with relevant departments in ensuring resolution to complex queries.
Applying in-depth knowledge and interpretation of both SAMA (South African Medical Association) and GEMS guidelines, including knowledge of ICD and CPT coding.
Applying the Scheme specific Rules to inappropriate claims E.g. scheme exclusions on (QES / MES).
Provide clinical interpretation and appropriateness of claims in accordance with Scheme Rules.
Positively influence and participate in change initiatives.

Competencies

Good written and verbal communication
Business Acumen
Client/ Stakeholder Commitment
Drive for Results
Leads Change and Innovation
Collaboration
Impact and Influence
Works independently
* Diversity and Inclusiveness