Consultant:Claims Management

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.
Grade 12Tertiary QualificationExperience Medical Scheme Administration Experience 2 years essentialExtensive understanding of the Administration System essentialKnowledge of Reference Price List essentialIn-depth knowledge of Medical Scheme Rules essentialMS OfficeMedical Scheme Act essentialKnowledge of Medical Aid Legislation and regulations essentialKnowledge of ICD 10 codes essentialKnowledge 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 CommunicationGood administration skill's, including record keeping and the ability to work under pressureMust maintain a high level of productivity to asses claims daily targets setHigh attention to detail in order to identify system risks or process shortfallsMust be quality aware and quantity orientatedOperating System knowledgeExcellent time management in order to manage deadlinesExcellent in query resolution
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