The role holder will be responsible forprocessing medical claims with a focus on controlling and management of member benefits through vetting of inpatient and outpatient bills. The role will report to the Assistant Manager-Medical Claims
Verify and capture outpatient and inpatient claims as per the claims manual
Assess medical claims documents for authenticity and process payments within set service levels
Register and process all reported medical claims and appoint relevant service providers where applicable and advice the clients on the required claims supporting documents
Raise payment requisitions within the set standards
Liaise with the finance department to ensure safe and timely dispatch of reimbursement claims cheques to clients
Ensure all claims documents are archived in the relevant systems Assist in case management activities
Promptly and efficiently attend to customer queries, and complaints
Deliver on performance requirements as defined in the departments’ strategy map, balanced scorecard and Personal Scorecard.
Gross Loss Ratio
Customer turnaround time
Accuracy in posting
Required to liaise and work closely with the other departments as may be necessary
Insurance sector players
Hospitals and other service providers
Knowledge, experience, and qualifications required
Diploma (Nursing and Medicine preferred)
1-2 years’ experience in medical claims
Knowledge of Britam health product
Learning and Researching: Rapidly learns new tasks and commits information to memory quickly; demonstrates an immediate understanding of newly presented information; gathers comprehensive information to support decision making at management level; learns from successes and failures and seeks colleague and customer feedback.
Working with People: Shows respect for the views and contributions of other team members; shows empathy; listens, supports and cares for others; consults others and shares information and expertise with them; builds team spirit and reconciles conflict; adapts to the team and fits in well.
Applying Expertise and Technology: Applies specialist and technical expertise; uses technology to achieve work objectives; develops job knowledge and expertise (theoretical and practical) through continual professional development; demonstrates an understanding of different organisational departments and functions.
Delivering Results and Meeting Customer Expectations: Focuses on customer needs and satisfaction; exhibits high standards for quality and quantity; monitors and maintains own quality and productivity; works in a systematic, methodical and orderly way; consistently achieves projects goals.
Following Instructions and Procedures: Follows procedures and policies; keeps to schedules; arrives punctually for work and meetings; demonstrates commitment to the organisation; complies with legal obligations and safety requirements of the role.
Adhering to Principles and Values: Upholds ethics and values; demonstrates integrity; accepts diversity; display individual responsibility towards the community and the environment; models the organisational values during every day interactions.