Junior Clinical Claims Adjudicator at Rand Mutual - RMA

Purpose:

The Junior Clinical Claims Adjudicator will report to the Claims Management Consultant, the incumbent will be responsible for effectively and efficiently processing pre-authorisations claims for COVID 19 incidents under the Compensation for Occupational Injuries and Diseases Act (COIDA).

Qualifications and Experience Required

• NQF Level 6: Diploma in Nursing/Allied Health/related field with additional certification
• Valid registration with professional body
• At-least 2-3 years Case Management/ Life Insurance/Medical Aid claims environment experience
• 2 - 3 years claims and contact centre related experience
• Additional insurance related qualifications or training (advantageous)
• Medical Knowledge at NQF6 level
• Knowledge of administrative and clerical procedures
• Computer literate - MS Office
• Knowledge of Customer Service principles and practices
• Valid Driver's License and own transport

Key Areas of Responsibility

• Capturing of COVID 19 claims, following up on outstanding documents from relevant stakeholders and indexing of documents
• Keep stakeholders informed and updated via various channels i.e. email, telephone, SMS etc. throughout the various stages of the claims processing cycle
• Servicing stakeholders telephonically and via email by resolving their queries
• Adjudicating and processing COVID 19 claims in an effective and efficient manner within the prescribed guidelines set out by RMA

Claims Management (end-to-end management of claims)

• Acknowledgement of COVID 19 claims upfront
• Communicate and articulate the claims process and requirements to the claimants and employers
• Gathering information, and sending follow-ups and reminders on outstanding claims documents
• Scanning of mail, documents, faxes, documents/images received from clients
• Identification and editing/correcting legibility of scanned documents
• Assist in checking the eligibility and validity of the members                      
• On an ongoing basis, ensure that there are no duplicate documents uploaded on the system
• Analyse documents received to produce the appropriate shades and best resolution in scanned reproductions
• Organise scanned documents on the local network

Claims processing and adjudication

• Manage COVID 19 claims aligned to treatment protocols and COIDA limits
• Manage costs associated with the authorisation and claims Estimates for all claims within their space
• Review and update ICD 10 codes based on First/Progress/Final Medical Reports/Investigation Results
• Review and update claims close to exceeding their Maximum Medical Improvement (MMI)
• Refer complex cases to the CCA for opinion and action accordingly

Capture and process payments for claims

• Prepare payment file for authorisation
• Capture and send payment on disease claims for authorisation as received from CCA’s

Attend to queries related to claims under management

• Handle all calls related to COVID 19 claims
• Handle queries related to COVID 19 cases and claims under their control and escalate where needed
• Maintain desk SLA through adherence to schedules, defined processes and workplan
• Follow-up on customer calls where necessary
• Document all call information according to standard operating procedures
• Complete call logs and issue reference numbers to customers
• Produce call reports
• Follow-up on initial contacts to determine customer satisfaction
• Manage and resolve customer complaints
• Provide customers with accurate product and service information in an efficient manner

Knowledge, Skills and Competencies required

• Knowledge of Claims processing, approval
• COIDA Knowledge
• Medical/Financial services knowledge
• Insurance sector knowledge
• ICD10 coding
• Knowledge of customer service principles and practices (Treating Customers Fairly)
• Good Administrative skills
• Strong communication skills
• Computer literate – Intermediate MS Office Suite
• Deadline driven
• Client centric personality
• Attention to detail
• Self-driven and independent