Medical Claims Management Specialist

Job Description

We are looking for an experienced Medical Claims Management Specialist to join our team. The successful candidate will be responsible for managing and administering the end-to-end medical claims process, ensuring claims are processed accurately, efficiently, and in compliance with applicable healthcare regulations, policies, and service level agreements.

Minimum Requirements

• Bachelor's Degree or National Diploma in Business Management, Business Administration, Healthcare Administration, Clinical Sciences, Nursing, or a related qualification.
• Minimum of 5 years' experience in a Medical Claims Management environment.
• Experience working with medical schemes, healthcare funders, health insurance, or medical claims administration.
• Knowledge of medical claims processing, adjudication, and healthcare funding.
• Understanding of healthcare legislation, medical coding, and tariff structures.
• Proficiency in Microsoft Office and medical claims management systems.
• Excellent analytical, communication, and problem-solving skills.

Responsibilities

• Manage the complete medical claims lifecycle from receipt to final settlement.
• Assess, validate, and adjudicate medical claims in accordance with policies and procedures.
• Investigate and resolve complex or disputed claims.
• Verify medical coding, tariffs, and supporting clinical documentation.
• Identify fraudulent, duplicate, or irregular claims and escalate where necessary.
• Liaise with healthcare providers, members, insurers, and internal stakeholders to resolve claims-related queries.
• Ensure compliance with healthcare regulations, medical scheme rules, and organisational policies.
• Maintain accurate claims records and prepare reports for management.
• Monitor claims turnaround times and ensure compliance with service level agreements.
• Recommend process improvements to enhance operational efficiency and customer service.

Preferred Skills

• Medical claims administration
• Claims adjudication
• Medical coding knowledge
• Healthcare funding
• Risk assessment
• Regulatory compliance
• Data analysis and reporting
• Attention to detail
• Customer service
• Time management

How to Apply

If you meet the above requirements and have the relevant experience, click Apply Now and submit your updated CV along with your qualifications.

Only shortlisted candidates will be contacted.

Work Location: Hybrid remote in Rosebank, Gauteng