Job Description

1. Role Purpose
The Junior Claims Administrator is responsible for capturing, validating and processing Cinagi Gap Cover claims in a timely, accurate and customer-centric manner.
The role supports the end-to-end claims process from first notification of loss to final outcome ensuring that all claims are handled in line with Cinagis policies, service standards and relevant regulatory and insurer requirements.
2. Key Responsibilities
2.1 Claims Intake & Registration

• Receive and log new claims via email, telephone, portals or integrated systems.
• Check that all required documentation has been submitted (claims forms, hospital accounts, medical scheme statements, clinical notes, etc.).
• Capture claim details accurately on the Cinagi claims system.

2.2 Validation & Assessment Support

• Perform initial validation checks (membership status, policy status, waiting periods, benefit eligibility, limits, etc.).
• Compare medical scheme payments vs. provider accounts to identify shortfalls in line with Gap Cover benefits.
• Flag incomplete or unclear documentation and request outstanding information from members, brokers or providers.
• Prepare claim files for review by the Senior Claims Administrator / Claims Assessor where required.

2.3 Member, Broker & Provider Communication

• Communicate clearly and professionally with members, brokers and providers regarding:

• Required documents
• Claim status updates
• Outcome explanations (approved/partially paid/declined)
• Respond to inbound queries within agreed service levels.
• Escalate complex or sensitive complaints to the Claims Manager timeously.

2.4 Processing & Administration

• Capture claim decisions and payment details on the system once authorised.
• Ensure all electronic records, notes and documents are complete, neat and correctly filed.
• Assist with preparing payment batches and reconciliations where required.
• Support monthly reporting and internal audit requests by providing accurate claim data.

2.5 Compliance, Quality & Controls

• Work in accordance with Cinagis internal processes, SLAs and quality standards.
• Adhere to relevant legislation and regulations (including POPIA, TCF principles and insurer guidelines).
• Maintain confidentiality of member and claims information at all times.

2.6 Continuous Improvement

• Identify recurring issues (e.g. missing documentation, common errors) and suggest process improvements.
• Participate in training sessions, product updates and system enhancements.

Education & Qualifications

• Grade 12 / Matric (essential).
• A relevant short course or certificate in insurance will be advantageous.
• RE 5(essential).

Experience

• Minimum 12 years experience in a claims or healthcare administration environment, preferably in one or more of the following:

• Gap Cover / top-up medical insurance
• Medical scheme / medical aid claims
• Health / life insurance claims
• Experience working with claim documents, hospital accounts and medical scheme remittance advices is strongly preferred.

Technical & System Skills

• Comfortable working on insurance/claims administration systems.
• Proficient in MS Office (especially Outlook, Excel and Word).
• Ability to learn new systems and digital tools quickly.

Skills Required