Medical Claims Assessor at Clear Leaf

Job Description
Receives and captures paper claims

• Receives batched claims from batch controller on a daily basis
• Pre-Assessing of claims on an all disciplines and schemes
• Reviews dependant history in accordance with Guidelines and Protocols
• Updates the batch control form ensuring 100% accuracy of captured data
• Captures member number, practice number, dependant code, date of service, tariff code, modifier, R-value and multipliers onto the system ensuring 100% accuracy of the captured data
• Checks as per system requirements for pre-authorizations
• Capturing of member payments where receipts and credit card payments are attached
• Allocates required benefit in accordance with protocols / grids / HOC
   

Reviews and actions paper claims:

• Reviews additional screens in order to source specific rejection codes
• Rejects the specific tariff code with the specific reject code in accordance with Guidelines and Protocols
• Updates the departmental batch control form ensuring 100% accuracy
• Forwards the completed batch to the Quality Controller for quality controlling purposes
• Forwards the batch control form to the Team Leader for pre-assessing verification
   

Reviews and actions electronic claims:

• Print original EDI from an outstanding excel report send to the assessor
• Review against the electronic claim to ensure 100% accuracy of data received
• Reviews additional screens in order to source specific rejection codes / HOC / hospital pre-auth
• Rejects the specific tariff code with specific reject code in accordance with Guidelines and Protocols

Qualifications

• Matric
• Minimum 5 years data capturing experience in a Medical Environment.
• Outgoing, professional and presentable;
• Motivated, independent and energetic;

Additional Information

• Salary: R12 000 – R15 000 per month depending on experience plus benefits