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.

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.

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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