Clinical Administrator / Clinical Specialist (Zestlife) MMH260728-1

Guardrisk

Role Purpose

To manage all clinical-related claim functions for GAP short-term insurance products.
To ensure claims are assessed accurately with appropriate clinical validation, PMB investigations, and pre-existing condition assessments.
To ensure all activities comply with Treating Customers Fairly (TCF) principles, delivering fair and effective customer outcomes.

Requirements

Education and Experience

Matric/Grade 12 National Senior Certificate or equivalent
Relevant qualification in a medical or related field (e.g., nursing, medical technology)
Minimum 2-3 years of experience within the life insurance industry in a clinical or claims assessment/administration role
Strong knowledge of medical aid schemes
Understanding of anatomy and physiology
Proficient in Microsoft Office and claims management systems

Duties and Responsibilities

Functions within the team as a Gap Claims Clinical Specialist / Specialist Administrator (multi-functional role):

To ensure that PMB allocations are made to MCA in accordance with the contract arrangement.
To investigate PMB internal claims with the relevant service providers and Medical Aids to ensure that the Drs invoice was correctly processed by the Medical Aid and to ascertain whether it is a valid shortfall claim to be covered by GAP.
To return claims to the claims assessor for updating when a successful PMB savings has been concluded.
To check and perform the PMB approval function in respect of MCA investigations and to return claims to the assessor for amendments where successful PMB or discount savings were achieved.
To investigate potential Pre-existing claims as per the product policy terms and conditions and to obtain more information from the client/dependant and relevant service providers pertaining to the client’s medical condition prior to the start of cover and for which the client is claiming for within the first 12 months. Ensure investigations is completed within 3 working days.
To recommend your pre-existing investigation outcome decision for claim approval or repudiation.
To negotiate discounts with service providers who have charged more than 2.5 times scheme tariff or for which the claim amount payable is over the threshold limit set by Zestlife from time to time.
To conduct certain reason code investigations when required, with the Medical Aid Scheme (e.g. 372 & 391) and provide feedback to the claim reviewer and management.
To ensure weekly follow-ups on PMB/Pre-ex investigations is done and to ensure that we do not exceed the SLA of 20 working days for investigations. Clients must be informed after 7 days that the claim is under clinical investigation with their Medical Aid or treatment providers.
To be logged into the Claims inbound telephone queue and to resolve all overflow calls received from start to finish in a professional and timeous manner as and whenever required.
To resolve all queries received within 24 – 48 hours.
To perform claim recovery follow ups and issue acknowledgement of refunds received communications.
To daily maintain and update your mailbox and workflow queue records for workflow management.
To keep track of your discounts negotiated and to reconcile it with the system extract each month.
To ensure investigation outcomes are communicated and the client’s expectations relating to the claim have been adequately addressed and managed using the template guidelines in an appropriate manner.
To be pro-active and to assist the clients with their queries by applying the TCF principles.
Be creative and use your initiative in resolving cases.
Think of working smarter and of ways to improve the process and to add value to the clients claim experience.
You are responsible to ensure that you fully understand the Zestlife products, the claims process and the systems so that you can operate efficiently and are competent in your job as a clinical specialist or specialist administrator.

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