The Claims Administrator is responsible for the accurate and timely processing, verification, and administration of medical insurance claims in accordance with company policies and insurance rules. The role ensures that claims are captured, assessed, and finalised efficiently, maintaining a high level of accuracy, customer service, and compliance with relevant medical insurance and regulatory requirements.

              Key Tasks

Claims Processing and Administration:

·       Receive, register, and process medical claims accurately and within receipt of all required documentation.

·       Verify member/dependents and provider details against system and policy information.

·       Ensure all claims documentation is complete and meets claim requirements.

·       Apply policy rules, benefit entitlement and exclusions correctly when processing claims.

·       Escalate complex or high-value claims for further review where necessary.

·       Allocate and capture claims onto the claims management system.

·       Data Capturing and Validation

·       Check ICD-10 codes, tariff codes, and procedure descriptions for accuracy and relevance.

·       Identify and flag discrepancies, duplicate claims, or potential fraudulent activity.

·       Reconcile claim information with supporting documents such as hospital accounts, pathology reports, and invoices.

Customer and Provider Liaison:

·       Communicate claim outcomes, payment details, and rejection reasons to members and service providers.

·       Handle claim-related queries via phone, email, or written correspondence professionally and timeously.

·       Maintain positive relationships with members. medical practitioners, hospitals, service providers and other internal departments.

·       Provide accurate information to members and service provider to provide excellent service.

·       Conduct security checks before information is disclosed to clients

·       Follow-up and provide ongoing feedback to claimants and service providers until claim is finalised.

·       Compliance and Quality Control

·       Adhere to company policies, insurance rules, and regulatory requirements (e.g., POPIA, FAIS guidelines).

·       Maintain confidentiality of member and provider information.

·       Participate in internal audits and implement corrective actions when required.

·       Conduct security checks before information is disclosed to clients

Engage With Members/Claimants and Service Providers Regarding Queries:

·       Check that all applicable documents are received and captured

·       Liaise with the relevant affiliations to resolve issues around incorrect or incomplete documentation

·       Obtain additional or missing information

·       Provide accurate information to clients to provide excellent service

·       Conduct security checks before information is disclosed to clients

·       Follow-up and provide ongoing feedback to claimants and service providers until finalised

·       Escalate completed claim to the Claim Assessor/Financial Claims team for final processing

·       Escalate any red flags/discrepancies, if identified, to the Supervisor/Team Leader.

Perform General Administrative Tasks:

·       Uphold tight SLA adherence throughout the entire claims processing activity.

·       Maintain strict adherence to all verbal or written instructions

·       Maintain strict compliance with company policies and regulatory requirements

·       Keep abreast of amendments to policy rules, benefit options, legislation, protocols, processes and systems

·       Undertake any other duties as determined by the business needs