Claims Quality Assessor (ADMED)

Introduction As a Claims Quality Assessor in our Admed department your role is to quality assess all claims processed by the Admed claims assessors checking for accuracy, completeness and validity. Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page. Role Purpose As a Claims Quality Assessor in our Admed department your role is to quality assess all claims processed by the Admed claims assessors checking for accuracy, completeness and validity. Requirements

• Matric /Grade 12
• Basic medical qualification an advantage (e.g. nursing or similar qualification)
• MS Office computer skills (MS Office suite)
• At least 3 years medical aid or gap cover claims processing and assessing experience
• At least 2 years insurance experience
• Basic knowledge of the local health and medical schemes industry, as well as an understanding of demarcation and legislation governing the local health industry.

Duties & Responsibilities

• Assessing all claims processed by the Admed claims team that is automatically allocated to your workflow in the OWLS system. Validating personal information, clinical information, documents attached, and that the decision made on the claim is correct
• Investigate all claims flagged by the OWLS system as a possible pre-existing condition within 2 working days and completing a detailed pre-existing register for each claim and record all the findings per claim worked
• Do quality assessments on claims returned from the external service provider post PMB and service provider negotiation
• Return claim to claims assessor as soon as possible and select the correct reason for the error picked up on a claim
• Finalisation and forwarding of quality assured claims for approval / rejection
• Detecting and acting on potential fraudulent claims
• Accurately and completely reviewing the clinical details of each claim received within 2 working days of receipt
• Quality assessing claims in accordance with practice guidelines, policy wording and protocols
• Ensuring a high level of service when liaising with individual and corporate customers, intermediaries, binder holders 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)
• Prepare detailed weekly and monthly reports, along with trend data, and submit to the Quality assurance manager
• Ensure that clients are treated fairly by investigating all claims with a possible pre-existing condition within a turnaround time of 2 working days and completing a detailed pre-existing register for each claim and record all the findings per claim worked
• Validating and quality assessing claims returned from the prescribed minimum benefit and service provider negotiation process

Competencies

• Strong customer service orientation with a passion for developing people and achieving excellence.
• Organized and focused, with the ability to work independently and effectively within a team.
• Self-driven and results-oriented, with a strong sense of responsibility and ownership.
• Analytical skills with attention to detail and accuracy.
• Resilient and able to work under pressure.
• Effective communication skills with all levels of staff.
• Computer literate and adaptable, with the initiative to go the extra mile when necessary.
• Disciplined, reliable, and possessing good time management skills.
• Ability to remain interested and focused when repeating processes.

Information :

• Company : Guardrisk
• Position : Claims Quality Assessor (ADMED)
• Location : Sandton, Gauteng
• Country : ZA