ROLE PURPOSE

 

To analyse and process specialised claims related to non-disclosure of medical conditions, ensuring strict compliance with Scheme Rules and Standard Operating Procedures. The role investigates suspected non-disclosures, assesses clinical and administrative evidence, engages with stakeholders, and recommends appropriate corrective actions to safeguard Scheme integrity and ensure fair claims processing.

 

Key Responsibilities


Functional Management

  • Assess specialised non-declaration and non-disclosure cases in line with Scheme Rules and SOPs.
  • Review, investigate and resolve escalated queries, complaints and special claims accurately and timeously.
  • Analyse quotations, motivations, medical information and claims documentation for compliance and correctness.
  • Conduct investigations into non-disclosure, including liaison with brokers, providers, internal teams and third parties.
  • Engage members telephonically and/or in writing to clarify medical history or obtain missing information.
  • Engage with all stakeholders professionally and confidentially on member related information.
  • Recommend corrective actions such as claim reversals, underwriting adjustments, member education or termination.
  • Maintain detailed case notes, ensure accurate system updates and track case progress to closure.
  • Identify trends, discrepancies, gaps and process inefficiencies to support continuous improvement.
  • Review and validate medical requests and clinical information for accuracy and integrity.
  • Support year-end testing, special projects and the enhancement of SOPs within the division.
  • Escalate complex or high-risk cases to Clinical or Legal teams for specialised review.
  • Engage with third party service providers to close identified gaps where non-declarations may open up the Scheme to undue risk
  • Review exception reports and look at avenues to effectively manage risk of non-declarations.

Risk & Compliance Management

  • Apply fraud-risk controls, governance principles and compliance measures in all assessments.
  • Support internal, external and ISO audit processes with accurate documentation.
  • Maintain adherence to ISO9001:2015 quality standards and related service level expectations.
  • Review and recommend improvements to Standard Operating Procedures.
  • Ensure compliance with all relevant legislation, policies and Scheme Rules.

Stakeholder Management

  • Build and maintain strong internal and external relationships to support case resolution and service optimisation.
  • Work collaboratively with business units, brokers, service providers and internal departments on non-disclosure cases.
  • Support cross-functional objectives through effective communication and information-sharing.


EXPERIENCE

QUALIFICATION

  • 3 Years Claims Assess
  • Minimum 5 years working experience in a medical Scheme/Medical Administrator
  • Technical knowledge minimum 5 years of NEXUS system experience

 

  • National Diploma in Nursing (General, Community Health, Midwifery, and Psychiatry) (NQF Level 6)

 

Knowledge

Skills

Attributes

  • Relevant legislation and regulatory frameworks
  • Risk Management practices and principles
  • Key Account Management
  • Business acumen
  • Technical problem solving
  • Claims Assessing
  • Annexures and Scheme rules
  • Medical Aid Industry
  • Verbal and Written Communication
  • Conflict management
  • Microsoft office
  • Negotiation
  • Resilience
  • Detail Orientation
  • Innovative Thinking
  • Customer Centric
  • Results Focused
  • Quality Focused
  • Compliance Driven
  • Analytical Thinking
  • Problem Solving
  • Assertiveness
  • Confidentiality
  • Active Listening
  • Judgement and Decision-Making

 

 

 
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