Claims Manager

Position

Purpose:

Effective management of the claims processing department, ensuring that claims are handled accurately, efficiently, and in line with the policies and guidelines of the medical aid scheme. Managing the financial risk associated with claims, enhancing the quality of service to members, and protecting the sustainability of the medical aid scheme.

Experience: 5 to 8 years’ solid management experience within a medical aid administration environment.

Qualifications: Tertiary qualification in related field.

• Oversee the day-to-day operations of the claims department.
• Ensure timely and accurate processing of medical aid claims in accordance with scheme rules.
• Review and authorize high-value or complex claims.
• Monitor and manage claim adjustments, denials, and appeals.

• Supervise, mentor, and evaluate the performance of claims staff.
• Provide training and support to ensure staff adherence to policies and procedures.
• Conduct regular team meetings to discuss performance, updates, and best practices.
• Plan and implement daily, weekly and/or quarterly operational changes within the team to respond to important external influences
• Ensure implementation of work plans in a way that maintains operational best practice and leads to continuous delivery improvement

• Ensure all claims are processed in compliance with scheme rules.
• Implement and maintain quality control procedures to minimize errors and fraud.
• Stay updated on changes in healthcare regulations and claim processing guidelines.

• Handle escalated customer inquiries and complaints with professionalism and efficiency.
• Work closely with policyholders, healthcare providers, and other stakeholders to resolve issues and provide clear explanations of claim decisions.

• Prepare and present regular reports on claims performance, trends, and departmental metrics.
• Analyse data to identify areas for process improvement and implement corrective actions.

• Develop and recommend improvements to claims processing procedures to enhance efficiency and accuracy.
• Collaborate with IT and other departments to integrate new technologies and systems

• Excellent leadership and team management skills.
• Exceptional analytical and problem-solving abilities.
• Strong communication and interpersonal skills.
• Proficiency in claims management software and Microsoft Office Suite (Excel, Word, PowerPoint).
• Attention to accuracy and detail.
• Ability to work under pressure and meet deadlines

• Knowledge and application of relevant legislation
• Knowledge and application of scheme rules

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.