Claims Quality Assessor (Admed)

As a Claims Quality Assessor within the Admed department you will be responsible for evaluating the quality of all claims processed by the Claims Assessors. Your role ensures that each claim is assessed accurately complies with policy rules and meets the required standards for completeness validity and correctness.

The purpose of this role is to conduct quality assessments on claims processed by the Admed Claims Assessors verifying accuracy completeness and validity and ensuring that each claim is processed correctly in line with the policy terms and conditions.

• 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
• Ensuring that all identified errors are communicated to the Claims Assessors with clear feedback and coaching to support improved accuracy and performance.
• 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
• Prepare detailed weekly and monthly reports along with trend data and submit to the Quality assurance manager
• Validating and quality assessing claims returned from the prescribed minimum benefit and service provider negotiation process

• 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
• Strong knowledge of medical claims billing practices including the correct use of diagnostic codes (ICD-10) medical procedure codes and modifier codes to ensure accurate complete and compliant claims processing as well as an understanding of demarcation and the legislation governing the Medical Gap Insurance industry.

• Ability to interpret medical claim documentation clinical notes and claims assessment outcomes.
• Strong customer service orientation with a passion for developing people and achieving excellence
• Highly 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.
• Strong Analytical skills with exceptional 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 required.
• Disciplined teachable and equipped with strong time management skills.
• Ability to remain engaged accurate and focused when completing repetitive processes