Claims Assessor

Position

Purpose:

To ensure that claim lines that require manual intervention are released efficiently and timeously, as per agreed TAT by applying assessing and Scheme rules.

Experience: A minimum of 2-3 years’ experience in a Managed Healthcare will be advantageous.

Qualifications: Tertiary qualification in related field.

• 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 elevate 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 elevate unresolved issues to higher levels
• Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery

Knowledge

• Knowledge and application of dispensing of meds, surgical material & procedures
• Application of financial and risk assessment methodology
• Knowledge of scheme rules and contractual negotiations
• Application of clinical intervention principles
• Advise on best practice health risk solutions to relevant parties
• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedure

Skills

• Emails / HIP / Excel / Word
• Negotiation and Telephone Skills
• Communication Skills
• Business Writing Skills
• Relevant systems knowledge and application
• Ability to negotiate and influence
• Problem Solving
• Numerical Ability
• Customer Focus
• Attention to Accuracy and Detail

Note:
Company reserves the right to close the advert before specified closing date.

PHA has its head office in Westville, Kwa Zulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.