ROLE PURPOSE

 

To provide professional, end-to-end query resolution across inbound calls and emails, ensuring accurate information, positive customer experiences, and compliance with Scheme rules, SOPs and service levels. The role also handles escalations, conducts detailed investigations and supports operational improvements.

 

Key Responsibilities


Customer Support & Query Resolution

  • Handle inbound calls and emails, ensuring full resolution within SLA.
  • Resolve escalated queries.
  • Provide accurate product, membership, claims and process information.
  • Investigate and reconcile complex queries, including claims-related issues.
  • Identify priority issues and route to relevant teams when required.
  • Initiate call-backs, print claims, update member profiles and log new member leads.
  • Document all interactions accurately and complete call logs and reports.

Problem Solving & Quality Service Delivery

  • Analyse reports and highlight trends for service improvement.
  • Conduct research to address complex customer needs.
  • Assist in training new team members and support knowledge sharing.
  • Record and resolve complaints timeously with professional feedback.
  • Direct members to correct service providers for managed care or authorisations.

Risk, Compliance & Governance

  • Apply fraud controls, governance and risk-prevention principles.
  • Support internal, external and ISO audits with accurate documentation.
  • Ensure all actions comply with SOPs, policies and Scheme rules.
  • Maintain and enforce Contact Centre SLAs and data-quality standards.
  • Act as SME to support SOP updates and optimisation.

Stakeholder Engagement

  • Liaise with members, brokers, providers and internal teams to resolve queries.
  • Provide exceptional service that strengthens member confidence.
  • Support business units with information and service-related collaboration.


EXPERIENCE

QUALIFICATION

  • Minimum 5 years in Customer Service
  • Minimum 5 years medical aid industry experience
  • Minimum 5 years working experience in a medical Scheme/Medical Administrator
  • Technical knowledge minimum 5 years of NEXUS system experience

 

  • Grade 12 / Matric
  • Diploma (Contact Centre or Customer Service related will be advantageous)

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
  • Clear understanding of Medical Schemes Act
  • Telephony Software
  • Verbal and Written Communication
  • Project Management
  • Decision-Making
  • Analytical Thinking
  • Conflict management
  • Problem solving
  • Presentation skills
  • Computer literacy
  • Self-management
  • Timekeeping
  • Report writing and analysis
  • Resilience
  • Detail Orientation
  • Innovative Thinking
  • Customer Centric
  • Results Focused
  • Quality Focused
  • Assertiveness
  • Compliance Driven
  • Emotional Maturity
  • Interactive Listening

 

 

 
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