Dental Claims Administrator

Introduction Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose To effectively review, process and manage benefit claims within service level agreements and according to company policies and procedures. A Dental administrator is a Claims and Pre-authorisation consultant, with a primary purpose on accurately and efficiently capturing claims and pre-authorisations on various platforms, ensuring compliance with organizational protocols and regulatory requirements. The role involves meticulous attention to detail, proactive problem-solving, and adherence to productivity targets to facilitate seamless claim processing.

Requirements

• National Senior Certificate / Grade 12 Certificate.

• 1-2 years of experience in claims processing or a similar field.

• Experience in assessing relevant insurance or medical aid claims, ideally with proficiency in both paper-based and Electronic Data Interchange (EDI) methods (Desirable).

• Knowledge of medical aid tariffs, disciplines, subcategories, modifiers would be an advantage.

• A comprehensive understanding of the legal and regulatory frameworks governing claims administration (e.g., knowledge of insurance laws, data privacy regulations, claims handling guidelines, and any other applicable legislation).

• Knowledge in both traditional paper-based claims assessment processes and electronic data interchange (EDI) systems.

• Knowledge in utilising claims operating systems and tools (i.e., industry-standard claims management software, databases, and other technological tools used in processing and documenting claims).

• Familiarity with the specific scheme or product rules governing the claims being processed (e.g., understanding the coverage, exclusions, limitations, and other relevant provisions specific to the insurance product or scheme being administered).

• A basic understanding of medical terminology, conditions, and assessments related to the claims being processed.

Duties & Responsibilities****Claim and Pre-authorisation Capture:

• Capture claims and pre-authorisations on multiple platforms with precision and accuracy.

• Verify patient and provider information, procedure details, and insurance coverage to ensure completeness and accuracy of captured data.

• Perform preliminary checks for duplicates before initiating claim capture to prevent errors and streamline processing.

System Issue Reporting:

• Report any system issues or discrepancies encountered during claim capture to designated stakeholders for resolution.c

• Collaborate with support teams to address technical issues promptly and minimize disruptions to workflow.

Batch Management:

• Close off claim and pre-authorisation batches once completed for a specific fund or timeframe.

• Log times and batches on the designated dashboard for statistical tracking and reporting purposes.

Platform Proficiency:

• Demonstrate proficiency in navigating and utilizing all relevant platforms for claim and pre-authorisation capture.

• Stay updated on platform updates, changes, and functionalities to ensure efficient and effective utilisation.

Communication and Documentation:

• Provide clear and concise documentation of claim processing activities, including any actions taken or notes added to the claim on different platforms.

• Communicate effectively with internal teams and stakeholders regarding claim status, issues, and resolutions.

Productivity Targets:

• Maintain productivity by capturing a minimum of 60 claims/pre-authorisations per day to meet established targets and deadlines.

• Prioritize tasks and manage time effectively to achieve daily productivity goals while maintaining accuracy and quality standards.

Competencies

• Interpreting Data.

• Following Procedures.

• Managing Tasks.

• Meeting Timescales.

• Adopting Practical Approaches.

• Making Decisions.