Claims Auditor

Manually intervene on claims flagged into auditing and apply clinical verification and preparation of medical quotations.

WHAT YOU’RE GOING TO DO

• Ensure that claims are audited as per instructions and are carried out correctly and in line with assessing guidelines
• Refer red flags to medical advisor for clinical input
• Ensure adherence to organisational best practice and legislative requirements
• Identify potential new rules that could be implemented as a cost saving measure
• Identify risks to the company while doctor profiling and escalate accordingly
• Maintain a consistent service delivery to ensure client retention and satisfaction by working within service level agreements
• Maintain broad product knowledge in order to effectively and accurately respond to customer queries.
• Ensure clear communication to all parties involved in an investigation in terms of outcomes and process
• Support effective teamwork
• Engage with appropriate training interventions to promote own professional development
• Actively live the Company values
• Interact with internal and external customers in an effective and efficient manner
• Basic knowledge and application of business administrative activities
• Ability to prepare written quotations based on assessing, legislative and scheme rule knowledge
• Accepts accountability for own mistakes and ensures corrective action is taken

WHAT YOU’LL NEED:

• Matric/Grade 12
• 3-5 years of experience in claims assessing on all medical disciplines is essential
• 1 year experience in the auditing of all medical aid claims is essential
• Thorough knowledge of the Oracle operating system
• Computer literacy (Email, Word and Excel) is an advantage
• The ability to interpret and apply claim and scheme rules correctly is essential
• Knowledge of the NHRPL(National Health Reference Price List)and SAMA tariffs is preferred

WHAT COMPETENCIES YOU’LL REQUIRE

• Resolves client problems within his or her job scope.
• Delivers within the parameters of Service Level Agreements
• Is engaged and demonstrates energy in the execution of tasks
• Accepts accountability for own mistakes and ensures corrective action is taken
• Completes assignments and tasks according to the predefined guidelines
• Improves ineffective work practices when required.
• Works cooperatively with others.
• Recognises own strengths and limitations.
• Engages with others and tries to understand individual differences

ADDITIONAL INFORMATION

Shortlisted candidates will be subjected to the following statutory checks:

• Credit
• Criminal
• References
• Qualifications

ABOUT

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value.

We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

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