Wednesday , April 24 2024

GEMS Jobs in Gauteng – Claims Specialist

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.

The total remuneration package for this position is R 862 628 – R 1 078 232 negotiable based on qualifications and experience.


Job Responsibilities:

The Claims Resolution Manager will be required to assist and support the Senior Manager Clinical and Transaction through the implementation of the following Key Performance Areas (KPAs)

  • 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.
  • Receive, investigate, resolve and report on claims processes including claims related complaints.
  • Identify and seek opportunities to maximise savings opportunities on claims whilst ensuring member is not compromised.
  • 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.
  • Monitor and report claims trends to management for awareness and assistance to resolve it may be too complex to be resolved at own level.
  • Collaborate, coordinate and communicate with internal and external stakeholders in a professional manner whilst assisting with resolving claims operational enquiries.
  • 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.
  • Analyse claims assessing systems and processes as part of understanding the root cause of claims complaints.
  • Ensure claims payment are paid in line with all guidelines and regulations.
  • Ensure claim queries are managed according to defined Scheme SLAs.
  • Develop and maintain knowledge of how rules, modifiers and technical aspects are used in programming and how these are licensed.
  • Carry out troubleshooting when the Scheme is having difficulties, working closely with stakeholders to sort out the problems with the processes and the actual claims payment.- Support Scheme’s product development activities.
  • Support Scheme’s Benefit design development activities.
  • Ensure an efficient and well-functioning claims platform.

Job Requirements:

  • Minimum 5 years’ experience with claims assessing, auditing and processing of medical aid claims.
  • Minimum 3 year Diploma/Degree in Medical/administration and finance Sciences.
  • Extensive experience in handling of EDI claims, paper claims and understanding of Switching house activities.
  • Extensive knowledge and understanding of clinical billing and clinical coding such as revenue codes, tariff codes and modifier usage.
  • Be organised and have good time management skills.
  • Be analytical and have the ability to manage priorities in a fast paced environment.
  • Have excellent written and verbal communication and interpersonal skills.
  • Have the ability to work well as part of a team, and deliver tasks timeously.
  • Be computer literate on an advanced level.
  • Be responsible and reliable.
  • Have a diligent work ethic with attention to detail.
  • Self-motivated and pro-active.
  • Be responsible and reliable.
  • Have a diligent work ethic with attention to detail.
  • Self-motivated and pro-active.
  • have resilient pressure management abilities.
  • Sound qualitative and quantitative analytical skills.
  • Good organisational ability and able to meet tight deadlines.
  • Accuracy and Attention to detail.
  • Must be in possession of a valid driver’s license and own vehicle and be willing to travel at short notice.
  • Clinical experience will be advantageous.
  • Medical Aid Claims
  • Clinical Billing
  • Clinical Coding
  • EDI Claims
  • Paper Claims
  • Switching House Activities
  • Medical Schemes Act

Job Details:

Company: Government Employees Medical Scheme – GEMS

Vacancy Type:  Full Time

Job Location: Pretoria

Application Deadline: N/A


Apply Here