ROLE PURPOSE

 

To provide support in resolving all referred and e-mail enquiries received based on pre-defined standard operating procures within a self-administered medical scheme environment; liaise with members, brokers and healthcare professionals, delivering an exceptional customer service.

 

Key Responsibilities


Functional Management

  • Resolve referred and emailed queries in a professional, accurate and timely manner, escalating where necessary.
  • Investigate and reconcile claims-related queries and provide comprehensive feedback in line with SOPs.
  • Ensure proper processing and resolution of claims according to Scheme rules, tariffs and procedures.
  • Provide advocacy and accurate product guidance to members.
  • Assist with credit control queries including arrears, suspensions, proof of payment and allocations.
  • Navigate, update and manage member, broker, and healthcare provider requests on internal
  • Escalate unresolved queries to the correct sub-division for further handling.
  • Serve as a back up to the Contact Centre as and when required.

Risk & Compliance

  • Adhere to fraud controls, compliance protocols and quality standards including ISO9001:2015.
  • Provide support and documentation during internal, external and ISO audits.
  • Review related Standard Operating Procedures in consultation with the Supervisor and Manager: Service Excellence Unit to ensure business optimisation.
  • Adhere to all relevant laws, policies and Standard Operating Procedures throughout the organisation.

Stakeholder Management

  • Build and maintain effective relationships with internal and external stakeholders.
  • Support business units to enable effective service delivery.

EXPERIENCE

QUALIFICATION

  • Minimum 5 Years in the Medical Aid industry
  • Minimum 5 Years Claims Assessment
  • Minimum 5 Years  experience in a Medical Scheme/Medical Administrator (not negotiable)
  • Minimum 5 Years’ experience in the role
  • Minimum technical knowledge 5 years of NEXUS experience
  • Grade 12 / Matric

Knowledge

Skills

Attributes

  • Relevant legislation and regulatory frameworks
  • Risk Management practices and principles
  • Business acumen
  • Technical problem solving
  • Claims Assessing
  • Annexures and Scheme rules
  • Verbal and Written Communication
  • Decision-Making
  • Conflict management
  • Computer Literacy
  • Resilience
  • Detail Orientation
  • Innovative Thinking
  • Customer Centric
  • Results Focused
  • Quality Focused
  • Compliance Driven
  • Analytical Thinking
  • Problem Solving
  • Claims Assessing
  • Assertiveness

 

 

 
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