Claims Specialist x2

  • To provide an effective and efficient service to clients by receiving, evaluating and responding to telephonic/electronic enquiries timeously.

Requirements

  • Grade 12/Matric.
  • Relevant tertiary qualification would be an advantage, Customer Relationship Management, Business.
  • Management, Project Management, and Operations Management.
  • Claims School Training.
  • 2 -3 years in the medical aid industry:
  • 2 – 3 years Claims processing experience within the medical aid industry.
  • 2 –3 years of query management experience.
  • 2 – 3 years of client service experience.
  • Good understanding of the MH systems would be an advantage.
  • Good written and verbal communication as well as Excel knowledge and application.
  • Understanding and knowledge of the interpretation and application of CMS, DoH, BHF, Private hospitals, etc.

Responsibilities And Work Outputs

  • Interaction with the Clinical Advisors i.e. Medical Advisors, Radiologist, Pathology.
  • Internal communication and relationship building.
  • Building and nurturing the SPN partnership.
  • Extensive interaction with Customer Experience
  • Communicates and interacts with Bureaus and Service providers.
  • Deliver meaningful and relevant feedback and communication.
  • Extensive communication within the GEMS BU as well as external service providers and bureaus.
  • Scrutinize all suspected inappropriate/ irregular claims appearing on the Metropolitan Expert Tool (QES /MES), (GP’s, Specialists, Allied Health and Radiologist) and ensuring appropriate processing.
  • Applying in-depth knowledge and interpretation of both SAMA and RPL rules, tariffs and modifiers,
  • Applying the Scheme specific Rules to inappropriate claims E.g. scheme exclusions on (QES / MES).
  • Investigate and actioning adhoc written enquiries from the business units.
  • Interact with the various medical advisors on an ongoing basis and to co-ordinate flow of queries.
  • Address correspondence pertaining to investigations and follow-ups.
  • Identify trends from QES/MES activities and referring Providers Profiles to forensics for investigation.
  • Provide clinical interpretation and appropriateness of claims in accordance with Scheme Rules.
  • Make recommendations to team leader/manager regarding new rules to be added to QES / MES rules engine.
  • Identify new risk areas and make recommendations to team leaders/manager.
  • Initiate correspondence pertaining to all Clinical Audit investigations both written and e-mail.
  • Respond to written communication and investigating to queries relating to Clinical Audit Departmentfunctions.
  • Liaise with Client Service, Claims and CMS regarding correspondence queries.
  • Check doctors claim history.
  • Determine what is settled and what must still be processed for payment.
  • Do the necessary rejections using the correct rejection codes.
  • Do necessary reversals where required.
  • Routing of claims or documents to the relevant departments.
  • Reprocessing of accounts from the Y- Pends.
  • Loading of appliance filters once approved by MHRS and Y-Pend to the filter queue for reprocessing.
  • Loading aPMB faxes filter on the filter screen once approved by MHRS and Y- Pend to the filter queue for reprocessing.
  • Hospital claims reversal requests received from MHRS to be reversed with reversal code 9929.
  • Review all medicines with nappi codes.
  • Reversal and reprocessing and submit to MediKredit.
  • Refereurgent special batches for urgent queries.
  • Reprocessing of Ex- gratia claims that are received from the ex-gratia department and provide feedback once completed.
  • Loading of rule and auth filters for Ex-gratia.
  • Load filters related to Appliance Approvals, Ex Gratia, PMB and Exclusions.
  • Provide ex-gratia with scheme rates when required.
  • Scrutinize, review, reverse and reprocess claims received as complaints from Customer Experience and Fund.
  • Provide written and/or telephonic responses to Customer Experience Team.
  • Review tariff modifier combination billings and apply it when processing claims.
  • Apply and understand Tariff codes, Tariff rules and Tariff pricing.
  • Liaise with internal clients as well as external clients (Members and Providers).
  • Identify errors by operators and e-mail the operator to fix error and cc both team leaders. Follow up within24hrs.
  • Management including knowledge of ICD and CPT coding.
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Competencies Required

  • Business Acumen.
  • Collaboration.
  • Client/ Stakeholder Commitment.
  • Impact and Influence.
  • Drive for Results.
  • Works independently.
  • Leads Change and Innovation.
  • Diversity and Inclusiveness.

Additional Information

  • Shortlisted candidates will be subjected to the following statutory checks:
  • ITC Checks.
  • Qualification Checks.
  • Reference Checks.
  • Psychometric assessments.

We reserve the right not to fill the vacancy. Should you not receive any response in respect of your application within 2 weeks, please consider your application unsuccessful.

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DISCLAIMER

Only on-line applications submitted via our careers page will be considered.
Internal Team Members must inform their manager of their application. Your manager must be aware of and support your application.

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