Claims Assessor ( Gap Cover)

CLAIMS ASSESSOR (Gap Cover"

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 action.
• 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.

Skills:

• 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 applicatio