Claims Administrator - Health

Job Overview

The Claims Administrator in the Health department is responsible for efficiently managing the receipt and routing of both physical and electronic claims and related correspondence within the organization, ensuring timely handling for internal and external stakeholders.

Key Duties and Responsibilities

• Prepare claims accurately and in line with departmental standards to facilitate proper processing.
• Verify that all claims include valid member and provider information and organize them into appropriate batches.
• Scan and distribute claim and correspondence batches to relevant departments.
• Investigate and resolve inquiries from customers and internal teams within established service level agreements, providing clear written or verbal feedback.
• Generate analytical reports on claims data using Excel.
• Confirm and verify member and provider details, sourcing missing information to ensure smooth claim processing.
• Communicate with providers to confirm coverage and benefits when necessary.

Stakeholders

Internal interactions include collaboration with the Operations, Finance, and Member Care teams. External stakeholders involve members and third-party service providers.

Decision Making

Responsible for decisions within the role’s scope, adhering to medical scheme rules and regulations.

Knowledge and Skills Required

• Intermediate understanding of tariff guides, product rules related to medical tariffs, and operating systems.
• Awareness of risk management and healthcare insurance industry standards.
• Attention to detail and analytical thinking at an intermediate level.
• Proficient in computer literacy, especially Microsoft Office tools.
• Basic communication abilities, both written and verbal.
• Root cause analysis and problem-solving skills rated at an intermediate level.

Educational and Experience Requirements

• Minimum of a Diploma certificate; relevant business certificates are advantageous.
• 2 to 3 years of essential experience in health or insurance claims assessment.
• Experience in general administration or data capturing within health or insurance sectors preferred.

Behavioural Competencies

• Adaptability and responsiveness to change.
• Strong adherence to principles and values.
• Ability to analyze and apply technology expertise.
• Managing pressure effectively and persevering through setbacks.
• Delivering results and meeting customer expectations consistently.
• Following instructions and procedures meticulously.
• Effective planning and organizing skills.
• Ability to work well with others and build relationships.