Junior Clinical Claims Adjudicator wanted urgently: Salary R350 000 annually
R 350000 Annually
The Junior Clinical Claims Adjudicator will report to the Claims Management Consultant, the incumbent will be responsible for effectively and efficiently processing pre-authorizations claims for COVID 19 incidents under the Compensation for Occupational Injuries and Diseases Act (COIDA).
Qualifications and Experience Required
NQF Level 6: Diploma in Nursing/Allied Health/related field with additional certification
Valid registration with a professional body
At-least 2-3 years Case Management/ Life Insurance/Medical Aid claims environment experience
2 – 3 years claims and contact centre related experience
Additional insurance-related qualifications or training (advantageous)
Medical Knowledge at NQF6 level
Knowledge of administrative and clerical procedures
Computer literate – MS Office
Knowledge of Customer Service principles and practices
Valid Driver’s License and own transport
Key Areas of Responsibility:
Capturing of COVID 19 claims, following up on outstanding documents from relevant stakeholders and indexing of documents
Keep stakeholders informed and updated via various channels i.e. email, telephone, SMS etc. throughout the various stages of the claims processing cycle
Servicing stakeholders telephonically and via email by resolving their queries
Adjudicating and processing COVID 19 claims in an effective and efficient manner within the prescribed guidelines
Claims Management (end-to-end management of claims)
Acknowledgment of COVID 19 claims upfront
Communicate and articulate the claims process and requirements to the claimants and employers
Gathering information, and sending follow-ups and reminders on outstanding claims documents
Scanning of mail, documents, faxes, documents/images received from clients
Identification and editing/correcting legibility of scanned documents
Assist in checking the eligibility and validity of the members
On an ongoing basis, ensure that there are no duplicate documents uploaded on the system
Analyse documents received to produce the appropriate shades and best resolution in scanned reproductions
Organise scanned documents on the local network
Claims processing and adjudication
Manage COVID 19 claims aligned to treatment protocols and COIDA limits
Manage costs associated with the authorisation and claims Estimates for all claims within their space
Review and update ICD 10 codes based on First/Progress/Final Medical Reports/Investigation Results
Review and update claims close to exceeding their Maximum Medical Improvement (MMI)
Refer complex cases to the CCA for opinion and action accordingly
Capture and process payments for claims
Prepare payment file for authorisation
Capture and send payment on disease claims for authorisation as received from CCA’s
Attend to queries related to claims under management
Handle all calls related to COVID 19 claims
Handle queries related to COVID 19 cases and claims under their control and escalate where needed
Maintain desk SLA through adherence to schedules, defined processes, and workplan
Follow-up on customer calls where necessary
Document all call information according to standard operating procedures
Complete call logs and issue reference numbers to customers
Produce call reports
Follow-up on initial contacts to determine customer satisfaction
Manage and resolve customer complaints
Provide customers with accurate product and service information in an efficient manner
Knowledge, Skills, and Competencies required:
Knowledge of Claims processing, approval
COIDA Knowledge
Medical/Financial services knowledge
Insurance sector knowledge
ICD10 coding
Knowledge of customer service principles and practices (Treating Customers Fairly)
Good Administrative skills
Strong communication skills
Computer literate – Intermediate MS Office Suite
Deadline driven
Client-centric personality
Attention to detail
Self-driven and independent
Ad Visible Until: 7 August 2020
Ref: JHB000563/Dee
Vacancy Type: Permanent
Apply Now
Source: Indeed
