Consultant:Claims Management at PPS

Job Advert Summary
To analyze, reconcile, process information on a Claims account. To assess various type of claims submitted electronically / paper or received via fax or e-mail.  Assessing must meet both quality and quantity set standards.  To do corrections on accounts as requested by other departments or the Scheme.  To complete Reversals as requested by Internal Clients or any other third parties.

Minimum Requirements

• Grade 12
• Tertiary Qualification

Experience

• Medical Scheme Administration Experience 2 years essential
• Assessing experience 2 years plus essential
• Extensive understanding of the Administration System essential
• Knowledge of Reference Price List essential
• In-depth knowledge of Medical Scheme Rules essential
• MS Office
• Medical Scheme Act essential
• Knowledge of Medical Aid Legislation and regulations essential
• Knowledge of ICD 10 codes essential
• Knowledge of PMB legislation essential

Duties and Responsibilities

• Reconcile member or provider claims received.
• Accurate daily assessing of targets.
• Manage quality error percentage.
• Ensure consistent and excellent application of set standards and Scheme Rules.
• Excellent administrative skills e.g. daily record keeping.
• Escalate requests for corrections to relevant Consultant.
• Follow up and resolve routed enquiries.
• Good Communication
• Good administration skill’s, including record keeping and the ability to work under pressure
• Must maintain a high level of productivity to asses claims daily targets set
• High attention to detail in order to identify system risks or process shortfalls
• Must be quality aware and quantity orientated
• Operating System knowledge
• Excellent time management in order to manage deadlines
• Excellent in query resolution