ROLE PURPOSE

 

To provide support in the analysis and processing of medical claims in accordance with the Scheme Rules, contractual agreements and Standard Operating Procedures ensuring accurate, efficient, and compliant claims administration. The role contributes to the integrity of the claims process quality assurance and cost containment and enables the Scheme to achieve its strategic objectives through effective service delivery and sound governance.

 

Key Responsibilities

Functional Management

  • Conduct quality reviews on assessed claims to ensure compliance with Scheme Rules, approved tariffs and
  • Standard Operating Procedures. Review, analyse and validate information on medical claims to ensure the accuracy, quality and integrity of submitted information.
  • Assess and resolve complex, high-value or escalated claims requiring advanced interpretation of benefits, tariffs and modifiers. Provide technical guidance on benefit interpretation, tariff application, modifiers, and claims processing requirements.
  • Identify trends in claim errors, discrepancies, or processing inefficiencies and recommend corrective actions to improve quality and operational performance.
  • Assist management in monitoring adherence to claims-related Service Level Agreements (SLAs) and quality standards within the claim’s environment.
  • Accurately capture and validate claim information on the relevant system and identify discrepancies, duplications, or irregularities where applicable.
  • Verify claim details including duration and application of modifiers, assistant, modifiers, approved tariffs, exclusions and applicable benefits.
  • Reverse and reprocess claims based on authorised instructions and ensure appropriate feedback and communication is provided to relevant stakeholders upon completion.
  • Manage the reversal and reprocessing of Prescribed Minimum Benefit (PMB) related claims and ensure correspondence is issued to relevant stakeholders as required.
  • Identify gaps or inefficiencies in claims processes and recommend
  • improvements to enhance service delivery, processing quality, and operational efficiency. Provide guidance, technical support and on-the-job training to junior assessors to ensure consistent application of Scheme Rules and operational procedures.
  • Identify gaps or inefficiencies in claims processes and recommend improvements to enhance service delivery, processing quality, and operational efficiency.
  • Participate in the review and updating of Standard Operating Procedures and work instructions to ensure alignment with operational requirements and governance standards.
  • Participate in user acceptance testing (UAT), system enhancements, and year-end testing to ensure system functionality aligns with Scheme Rules and operational requirements.
  • Participate in user acceptance testing (UAT), system enhancements and year-end testing to ensure system functionality aligns with Scheme Rules and operational requirements. Provide subject matter expertise during system upgrades, benefit changes, and process improvement initiatives.

Risk & Compliance

  • Identify and escalate potential fraud risks, irregular billing patterns and suspicious claims in line with the Scheme’s fraud prevention controls.
  • Apply sound governance, risk-management principles and internal controls during claims assessments to ensure compliance with Scheme Rules and regulatory requirements.
  • Provide supporting documentation and subject matter input for internal, external and ISO audits processes and assist in addressing audit findings where required.
  • Ensure adherence quality management standards aligned to ISO9001:2015 and support continuous improvement initiatives within the claim’s environment.
  • Monitor compliance with claims-related Service Level Agreements (SLAs) and escalate deviations to management to mitigate operational risk.
  • Participate in the review and enhancement of claims-related Standard Operating Procedures to strengthen governance and operational efficiency.

Stakeholder Management

  • Build and maintain effective working relationships with internal and external stakeholders, including service providers, administrators, and business units, to facilitate effective communication, expectations management, and collaboration. Provide technical support and guidance to internal business units on claims-related queries, benefit interpretation, and operational processes to support service delivery objectives.
  • Assist in resolving escalated claims queries from stakeholders by providing accurate information and recommendations in line with Scheme Rules and operational procedures.
  • Support cross-functional collaboration with relevant departments to ensure alignment in achieving the Scheme’s operational and strategic goals.
  • Contribute to knowledge-sharing across departments to improve understanding of claims processes, benefit structures, and operational requirements.

EXPERIENCE

QUALIFICATION

  • 5 Years Experience in Claims Assessment
  • 5 Years’ Experience working on Nexus systems
  • 5 Years in the Medical Aid industry
  • 5 Years experience in a medical (not negotiable) scheme/administrator experience
  • Grade 12 / Matric / NQF Level 4
  • Any qualification higher than that will be advantageous

Knowledge

Skills

Attributes

  • Relevant legislation and regulatory frameworks (Medical Schemes Act, PMB Regulations, POPIA, FAIS where applicable)
  • Risk Management practices and principles
  • Key Account Management
  • Business acumen
  • Technical problem solving
  • Claims Assessing
  • Annexures and Scheme rules
  • Medical Aid Industry
  • Healthcare coding and tariff structures (ICD, CPT where applicable, modifiers)
  • Fraud detection and claims risk indicators
  • Quality assurance and claims auditing principles
  • Claims administration systems and workflow processes
  • Process improvement principles
  • Verbal and Written Communication
  • Conflict management
  • Microsoft office
  • Negotiation
  • Analytical and Problem-Solving Skills
  • Attention to Detail
  • Stakeholder Engagement
  • Coaching and Knowledge Sharing
  • Time Management and Prioritisation
  • Quality Assurance Skills
  • Resilience
  • Detail Orientation
  • Innovative Thinking
  • Customer Centric
  • Results Focused
  • Quality Focused
  • Compliance Driven
  • Analytical Thinking
  • Problem Solving
  • Assertiveness
  • Active Listening
  • Judgement and Decision-Making

 

 

 
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