Claims Specialist x2

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


  • 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.

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.


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.

Other Opportunities You Might Like: