Claims Assessor ( Gap Cover)

CLAIMS ASSESSOR Position Purpose To ensure that all paper Gap claims are accurately captured into the iMed system

Experience

3 years relevant healthcare industry, short term insurance and credit data capturing and claims processing experience

Qualifications

Matric and RE5 Required

Accountabilities

Client service delivery and quality:

• Follow procedures and cooperate with peers and leader for best possible service delivery Compliance and Risk Management:

• Defined legal, statutory and regulatory compliance is maintained at the required standards

• Operational risk and governance structures, measures and frameworks are complied with and necessary action is taken to address issues, when necessary Financial Management:

• Contribute to cost savings within the department to assist with financial goals and targets

Operating Model:

• Conduct accurate and effective intervention/reconciliation of administration on all allocated claims

• Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement

• Continuously apply relevant rules

• Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims

• Rectify incorrect information on claims and escalate where required

• Reconcile claims where required and communicate outcome

• Ensure correct payments to vendor or member

• Meet delivery objectives through working with other team members within and linked to the department / project

• Resolve operational performance variations and problems and escalate unresolved issues to higher levels

• Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery Operational Implementation of Strategy:

• Keep up to date with operational changes implemented in response to important external influences

• Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities

• Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement.

Operational Leadership:

• Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives

• Engage in development, coaching and mentoring

• Support transformation through valuing diversity

• Behave in alignment with the Afrocentric values

Stakeholder Management:

• Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies

• Identify, investigate, respond to and refer IT assessing queries appropriately

• Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved

• Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in

Position Specific Outputs

• Duplicate check claims received, and process claims and emails according to processes.

• Capture all claims received in accordance with relevant legislation and processes.

• Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes

• Providing coding review and resolution on call centre queries

• Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes

• Communicate with Stake holders

• Maintain clinical documents and processes

• Review and action QA reports and provide corrective actioning

• Assist with training and sharing of knowledge within the team and clients

• Assist on the various Call centres

• Assist with call centre call backs.

• Review and assess gap claims.

• Verify documentation and ensure all required information is completed.

• Communicate with clients and stakeholders to gather necessary information.

• Process claims efficiently and accurately.

• Maintain detailed records of claims and assessments.

• Collaborate with other departments.

• Assist with departmental Adhoc duties where required.

Position Specific Outputs 2 Competency Requirements

Knowledge:

• Knowledge and application of relevant legislation

• Knowledge and application of processes and procedures

• Knowledge of scheme rules and contractual negotiations

Skill:

• Problem solving and decision making skills

• Business Writing Skills

• Communication Skills

• Computer Technology Skills

• Task Management

• Adobe Creative Suite

• Data modelling and evaluation

• Attention to Accuracy and Detail

• Numerical Ability

• Customer Focus

• Multitasking

• Strong analytical and problem solving skills

• Proficiency in Microsoft Office Suite

• Relevant systems knowledge and application