Claims Accounts Authoriser Tier 1 at FEM

Job Description

• FEM is seeking a detail-oriented and analytical Tier 1 Claims Accounts Authoriser to support the accurate, compliant, and timely authorisation of injury-on-duty related medical accounts. This role plays a critical financial control and risk mitigation function, ensuring that claims payments are processed in accordance with gazetted tariffs, COIDA legislation, internal SOPs, and service-level agreements.
• The successful candidate will be responsible for authorising low to moderately complex medical accounts, including Temporary Total Disablement (TTD) and Permanent Disability (PD) claims, while remaining highly alert to potential risks such as fraud, duplicate billing, coding errors, and unnecessary expenditure.
• This role is instrumental in safeguarding FEM against financial loss, ensuring payment integrity, and supporting efficient claims processing within a highly regulated environment.

Key Responsibilities

The key responsibilities of the role include:

• Accurately and timeously authorising Tier 1 medical accounts in line with gazetted tariffs and internal SOPs
• Verifying supporting documentation for validity, completeness, and alignment to billed services
• Applying correct COID tariff codes and verifying correct billing structures
• Identifying discrepancies, overcharging, duplicate billing, inflated charges, and potential fraudulent claims
• Authorising Temporary Total Disablement (TTD) payments in accordance with COIDA and internal rules
• Authorising Permanent Disability (PD) payments, including verification of calculations and supporting documentation
• Conducting checks to prevent overpayments and duplicate payments
• Maintaining strict adherence to turnaround times and service-level standards
• Supporting ad hoc authorisation tasks, including wages, sundry accounts, and operational transactions when required
• Providing support during high-volume or high-pressure periods while maintaining quality and accuracy
• Supporting internal and external audit processes by maintaining accurate records and clean audit trails
• Promoting a strong control environment and zero tolerance for errors, non-compliance, or reputational risk
• Maintaining professional and service-oriented engagement with policyholders, service providers, and internal stakeholders

Education Requirements

Minimum:

• Matric
• 2–3 years’ experience in an insurance or medical aid claims environment
• COIDA qualification or practical COIDA experience
• Strong COIDA qualification and medical claims experience will be advantageous

Experience Requirements

Minimum:

• At least 2 years’ experience in an insurance or medical aid claims environment
• At least 2 years’ experience in a related claims or medical accounts processing role

Training and Knowledge

• Experience and understanding of medical tariffs
• Claims authorisation experience
• Knowledge of the Compensation for Occupational Injuries and Diseases Act (COIDA)
• Strong MS Office skills
• Good understanding of insurance products and claims processes
• Deep familiarity with medical tariff structures and coding (advantageous)
• Strong ability to identify anomalies, red flags, and control breakdowns
• Excellent time management and organisational skills
• Effective communication with internal and external stakeholders
• Experience in medical accounts processing within a COID environment (advantageous)

Key Competencies

• High attention to detail and accuracy
• Strong analytical and problem-solving skills
• Ability to work under pressure and meet strict turnaround times
• Strong ethical standards and commitment to governance and compliance
• Ability to apply judgment within defined authority levels
• Professional customer service orientation