ROLE PURPOSE To investigate, manage and resolve escalated complaints across all Scheme channels, ensure end-to-end case resolution, improve process effectiveness, and support customer satisfaction through professional engagement, insight reporting and risk-aware decision-making. |
Key Responsibilities
Complaints & Case Resolution - Handle escalated enquiries requiring specialised knowledge and judgement.
- Resolve complex issues relating to authorisations, claims, processes and service failures.
- Conduct root-cause analysis and recommend corrective actions.
- Engage with clinical teams, managed care partners and medical providers to validate information and support case decisions.
- Ensure timely feedback, customer recovery and closure of all cases.
Operational Delivery & Process Improvement - Identify process gaps and drive improvements to enhance service quality.
- Maintain accurate case records, metrics and operational reporting.
- Support daily operational delivery aligned to SLAs and governance standards.
- Draft, refine and support updates to policies, SOPs and internal controls.
- Act as Subject Matter Expert (SME) within the team and ensure high-quality work outputs.
Risk, Compliance & Quality Assurance - Apply fraud controls and risk-management principles during investigations.
- Ensure compliance with Scheme Rules, legislation and ISO9001 processes.
- Contribute to internal and external audit requirements.
- Escalate aging or high-risk matters to leadership when necessary.
People & Stakeholder Engagement - Collaborate with cross-functional teams for efficient query resolution.
- Build strong relationships with members, brokers, providers and internal teams.
- Support upskilling, coaching and knowledge-sharing within the Complaints Unit.
- Participate in meetings and communicate trends and insights.
EXPERIENCE | QUALIFICATION |
- Minimum 5 years in Customer Service
- Minimum 5 years working experience in a medical Scheme/Medical Administrator
- Technical knowledge 5 years of NEXUS system experience
- Minimum of 2 years escalation management experience
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- National Diploma in Nursing (General, Community Health, Midwifery, and Psychiatry) and/or any other related diploma
- RPL applicable
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Knowledge | Skills | Attributes |
- Relevant legislation and regulatory frameworks
- Risk Management practices and principles
- Business Acumen
- Annexures and Scheme rules
- Technical problem solving
- Medical Insurance
- Call Centre Systems and processes
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- Verbal and Written Communication
- Project Management
- Coaching and Mentoring
- Decision-Making
- Analytical Thinking
- Conflict management
- Problem solving
- Presentation skills
- Computer literacy
- Customer centric
- Report writing
- Process orientated
- Decision-making
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- Resilience
- Detail Orientation
- Innovative Thinking
- Customer Centric
- Results Focused
- Quality Focused
- Assertiveness
- Compliance Driven
- Innovative thinking
- Emotional Maturity
- Interactive Listening
- Conflict resolution
- Investigative skills
- Resolution orientated
- Detail orientated
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