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Claims Assessor- Gap Cover

Johannesburg
Salary: R1 000.00 Per Month
Job Type: Contract
Sectors: Insurance Management
Reference: 174616

Apply before Mar 31 2026 | 25 Days left

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External Application

Vacancy Details

Employer: Moladira Skills

Position Purpose
To ensure that all Gap claims are accurately captured into the iMed system

Experience

1 Year Gao cover experience.
3 years relevant healthcare industry, short term insurance and credit data capturing and claims processing experience.

Qualifications
Matric and RE5(Advantageous)

Position Specific Outputs

Duplicate check claims received, and process claims and emails according to processes.
Capture all claims received in accordance with relevant legislation and processes.
Review and process case and non - case related claims in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
Providing coding review and resolution on call centre queries
Assess claims edit requests and actioning it in accordance with coding principles, scheme rules and benefits, and managed care policies and processes
Communicate with Stake holders
Maintain clinical documents and processes
Review and action QA reports and provide corrective actioning
Assist with training and sharing of knowledge within the team and clients
Assist on the various Call centres
Assist with call centre call backs.
Review and assess gap claims.
Verify documentation and ensure all required information is completed.
Communicate with clients and stakeholders to gather necessary information.
Process claims efficiently and accurately.
Maintain detailed records of claims and assessments.
Collaborate with other departments.
Assist with departmental Adhoc duties where required.

Operating Model:

Conduct accurate and effective intervention/reconciliation of administration on all allocated claims.
Accurately and efficiently process allocated claims according to the defined process and within Service Level Agreement.
Continuously apply relevant rules.
Follow documented Assessing policies and procedures pertaining to manual intervention and reconciliation of claims.
Rectify incorrect information on claims and escalate where required.
Reconcile claims where required and communicate outcome.
Ensure correct payments to vendor or member.
Meet delivery objectives through working with other team members within and linked to the department / project.
Resolve operational performance variations and problems and escalate unresolved issues to higher levels.
Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery.

Operational Implementation of Strategy:

Keep up to date with operational changes implemented in response to important external influences
Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement

Operational Leadership:

Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
Engage in development, coaching and mentoring
Support transformation through valuing diversity
Behave in alignment with the Afrocentric values

Stakeholder Management:

Investigate (through contacting relevant internal parties, providers or members), respond to and resolve valid claims and assessing queries or anomalies.
Identify, investigate, respond to and refer IT assessing queries appropriately.
Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved.
Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in.

Competency Requirements

Knowledge:

Knowledge and application of relevant legislation
Knowledge and application of processes and procedures
Knowledge of scheme rules and contractual negotiations

Skill:

Problem solving and decision making skills
Business Writing Skills
Communication Skills
Computer Technology Skills
Task Management
Adobe Creative Suite
Data modelling and evaluation
Attention to Accuracy and Detail
Numerical Ability
Customer Focus
Multitasking
Strong analytical and problem solving skills
Proficiency in Microsoft Office Suite
Relevant systems knowledge and application

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About Moladira Skills

Historical Footprint
Moladira Skills, founded in 2016 by Douglas James, emerged from his extensive expertise in the Flexible Recruitment and Skills Development sectors. With a notable background at companies like Kelly Group, Douglas played a pivotal role in devising and implementing innovative sourcing strategies for our corporate clientele, aligning with evolving labor regulations.

Having honed his experience in labor-intensive domains such as call centers and corporate accounts, Douglas recognized significant opportunities to enhance employment creation and bolster organizations. Moladira Skills strives to support companies on their path to sustainability and growth within the SMME and Informal Markets, offering flexible commercial solutions that align with their aspirations.

Who are we?

Pronounced - Molā-Deera or simply Molādira,
the name which belongs to the founder of the agency's late grand mother who had many good qualities and principles which can relatively be found in the Company today.

Moladira Skills is a recruitment and HR administration agency who value convenience and quality people.

What we stand for
Mission
Our Mission is to accelerate the time to fill roles, accelerate the increase in new opportunities for the unemployed and stimulate SMME Growth through leveraging legislation.

Vision
Our Vision is to be part of the many organizations that is making a meaningful contribution to increase the number of REAL/NEW job opportunities through various programmes with the SMME’s and informal sector.

Values
Being Human, Ownership & Accountability, Life Long Learning, Innovation and Flexibility, To Give, To Do and Be better, Authenticity, Engagement