Re-advertisement: Medical Scheme Claims Assessor x3 (6 months contract) at Rand Water

Job Advert Summary    

• Rand Water is looking for three (3) Medical Scheme Claims Assessors to manage daily operational requirements of the Rand Water Medical Scheme for claims assessing (auditing) and monitoring requirements for clinical IT administration system enhancements; align with Scheme rules and clinical protocols. Candidates with BCur Nursing degree or Diploma in General Nursing with Midwifery, Psychiatry and Community Health/ Diploma in General Nursing and Diploma in Midwifery/ Diploma in General Nursing and (Diploma in ICU/ Theatre and/or Trauma are encourgaged to apply.

Minimum Requirements    

• Grade 12
• B Cur Nursing degree or Diploma in General Nursing with Midwifery, Psychiatry and Community Health/ Diploma in General Nursing and Diploma in Midwifery/ Diploma in General Nursing and (Diploma in ICU/ Theatre and/or Trauma will be an added advantage)
• 2 – 3 years experience in a private hospital setting
• 2 – 3 years experience working for a Medical Scheme (closed or open Scheme)
• Experience in claims assessing knowledge of ICD10 Codes, Tariff Codes, Modifiers, and critical Clinical protocols.

Primary Duties    

• Process various types of medical scheme claims through clinical protocols and scheme rules 
• Provide excellent quality customer service to clients (electronically, walk in, telephonically and on roadshows)
• Updating policies and procedures through creative and innovative ideas as per scheme business processes utilizing available resources to improve operational inefficiencies
• Identifying gaps on the IT Admin System , logging requests for system enhancement to the DSP
• Compile monthly operational reports and provide to the Medical Scheme Supervisor for review
• Sound knowledge of ICD10 Codes, Tariff Codes, Modifiers, and critical clinical protocols

Knowledge    

• Medical Scheme background
• Knowledge of Medical Scheme Schemes No 131 of 1998 and its Regulation as amended
• Knowledge of Council of Medical Scheme
• Computer literacy (MS Office suite)

Skills    

• Good interpersonal skills
• Strong communication (written & Verbal)
• Team player
• Problem solving abilities
• Planning and organizing
• Report Writing Skills

Attitude    

• Accuracy and attention to details
• Time management
• Deadline orientated
• Self-starter
• Analytical thinker
• Customer oriented
• Integrity
• Innovative & creative
• Ability to work under pressure