Claims Assessor ( Gap Cover)

Moladira Skills

Position Purpose

To ensure that all paper Gap claims are accurately captured into the iMed system

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

Matric and RE5 Required

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

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.