JOB TITLE :Claims Administrator

DEPARTMENT :Health

REPORTING TO : Health Operations Manager

Job Purpose
To ensure that all electronic and physical claims and correspondence received in the business are routed timeously to all levels within the organisation, for both internal and external stakeholders. 

Key Responsibilities

• To ensure all claims are prepared in accordance with departmental standards, in order to ensure that claims are processed accordingly 
• To ensure that all claims have valid member / provider details and are placed in batches
• To scan all claim and correspondence batches and route to the relevant department.
• To ensure that all enquiries from both internal and external customers are investigated and resolved within the SLA and to provide either written or verbal feedback to the relevant stakeholder.
• To compile reports, utilising Excel, based on claims received.
• To verify member and provider details and source outstanding information, in order to enable accurate and swift processing of claims.
• To liaise with providers confirming cover and benefits, where necessary 

CUSTOMERS / STAKEHOLDERS 

Internal  

• Operations team 
• Finance Team 
• Member Care 

External

• Members 
• 3rd Party Service Providers 

DECISIONS
Decisions as outlined by the scope of role and responsibilities in line with the rules and regulations of the medical scheme.

TIME HORIZON 
Short Term 

KNOWLEDGE 

SKILLS 

EDUCATION 

EXPERIENCE 

BEHAVIOURAL COMPETENCIES
Behavioural success factors that are either pertinent to the role or carried out on a daily basis. These are the observable behaviours or personal attributes (actions, verbal or non-verbal cues) that you would see on a daily basis. Please bear in mind that the 8 chosen are the most important behavioural attributes – the others as listed may well be relevant too although not as essential to daily operations