GEMS Call Centre Vacancies – Claims Specialist

  • Full Time
  • Pretoria

Website Government Employees Medical Scheme - GEMS

Job Description:

The position of Claims Resolution Manager is vacant. The Claims Resolution Manager will report directly to the Senior Manager Clinical and Transaction and forms part of the Administration and Transaction Services Division. The position is based at Head Office in Pretoria.

Job Responsibilities:

  • Analyse claims assessing systems and processes as part of understanding the root cause of claims complaints.
  • Support the division by managing and testing claims processes at the division’s service providers.
  • This includes evaluation, investigation and mitigations being put in place to prevent claims processing failings.
  • Collaborate, coordinate and communicate with internal and external stakeholders in a professional manner whilst assisting with resolving claims operational enquiries.
  • Identify and seek opportunities to maximise savings opportunities on claims whilst ensuring member is not compromised.
  • Ensure claims payment are paid in line with all guidelines and regulations.
  • Monitor and report claims trends to management for awareness and assistance to resolve it may be too complex to be resolved at own level.
  • Develop and maintain knowledge of how rules, modifiers and technical aspects are used in programming and how these are licensed.
  • Receive, investigate, resolve and report on claims processes including claims related complaints.
  • Ensure claim queries are managed according to defined Scheme SLAs.
  • Interrogate claims to unpack the root cause of claim complaints from members or providers-
  • Identify wasteful claims using claims assessing techniques with recommendations on remedial actions to reduce the scheme exposure to financial loss.
  • Conducting systemic reviews of good practice guidelines currently available to ensure that Scheme funding decisions are based on best practice. This activity aims to ensure that these elements are sound and in compliance with the Medical Schemes Act and Regulations, as well as the Scheme Rules at all times.

Job Requirements:

  • Extensive knowledge and understanding of clinical billing and clinical coding such as revenue codes, tariff codes and modifier usage.
  • Extensive experience in handling of EDI claims, paper claims and understanding of Switching house activities.
  • Minimum 3 year Diploma/Degree in Medical/administration and finance Sciences.
  • Self-motivated and pro-active.
  • Be computer literate on an advanced level.
  • Be organised and have good time management skills.
  • Good organisational ability and able to meet tight deadlines.
  • Sound qualitative and quantitative analytical skills.
  • Minimum 5 years’ experience with claims assessing, auditing and processing of medical aid claims.
  • Be responsible and reliable.
  • Be analytical and have the ability to manage priorities in a fast paced environment.
  • Have the ability to work well as part of a team, and deliver tasks timeously. have resilient pressure management abilities.
  • Have a diligent work ethic with attention to detail.
  • Have excellent written and verbal communication and interpersonal skills.

Job Details:

Company: Government Employees Medical Scheme – GEMS

Vacancy Type: Full Time

Job Location: Pretoria

Application Deadline: N/A

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