Claims Assessor - Sandton at Guardrisk

Role Purpose    

• Processing of medical expense shortfall (gap cover) claims in accordance with stipulated service levels and in terms and conditions of cover as defined in policy wording.

Requirements    

• Matric 
• Basic medical qualification an advantage (e.g., nursing or similar qualification)
• Computer Literacy (MS Word, Outlook, and Excel)
• FAIS Fit and Proper including RE5
• At least 2 years medical or short-term health and accident insurance claims handling experience
• At least 2 years client servicing experience
• A good knowledge of the local healthcare industry

Duties & Responsibilities    

• Ensuring that the principles and outcomes of TCF (Treating Customers Fairly) are practised and achieved in all duties performed and services provided to Admed customers
• Ensuring the cradle-to-grave coordination of all gap claims received electronically from contracted medical schemes with the objective of achieving an entirely seamless claims experience for mutual customers
• Dealing with client and medical scheme queries as and when they arise within the stipulated timeframe
• Receiving of new Seamless claims via Secured sites and emails, importing them into the system – including the updating of members’ personal details – onto claim administration system on the same day or within 48 hours of receipt
• Ensuring that claims data is successfully received from all contracted medical schemes in the correct electronic format and in accordance with agreed SLA’s
• Ensuring the ongoing successful importing of claims data into the claim administration system
• Interacting with relevant medical schemes via e-mail or telephone in respect of outstanding information or claims documentation, on the same day or within 48 hours of receiving or capturing the claim
• Ensuring that all registered claims are assessed and administered effectively and efficiently in terms of the relevant and prevailing legislation and policy wording
• Accurately and completely capturing the clinical details of a claim on the claim administration system on the same day or within 2 working days of receipt
• Prioritizing claims where outstanding documentation has been received – ensuring that these documents are captured within 48 hours of receipt
• Assessing claims in accordance with practice guidelines, policy wording and protocols
• Finalisation and forwarding of claims to the quality assurance team for approval / rejection
• Ensuring prompt handling and feedback on claims
• Responding to capture queries received within 48 hours of receipt
• Detecting and acting on potential fraudulent claims
• Ensuring a high level of service when liaising with individual and corporate customers, intermediaries, binder holders, Medical schemes and colleagues
• Ensuring that the principles of TCF are delivered across every function performed, with a specific focus on the achievement of TCF Outcome 6 (Customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim or make a complaint)
• Where relevant, engaging with the Admed claims team and the respective medical schemes in respect of changing benefits and protocols, updating system rules and data file specifications
• Liaising with the contracted medical schemes in respect of all the claim's integration matters, including challenges, changes, etc
• Liaising with the Guardrisk IT Department and its appointed external developers in respect of system requirements, changes and problems
• Monitoring of claims-related system communication with customers, to ensure that customers are always kept up to date during the claims process

Competencies    

• Results and solutions driven
• Strong focus on client centricity and service excellence
• Strong problem solving and decision-making capability
• Organised and focused
• Analytical skills with attention to detail
• Resilience and ability to work under pressure
• Adaptability and self-discipline
• Effective communication skills and ability to professionally manager customers
• Disciplined and reliable
• A team player