To process claims, generate remittances, initiate payments and conduct claims reconciliations with medical service providers.

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The following key outputs are required from this role.

• Timely verification and vetting of all medical provider claims/invoices.
• Prompt generation of remittances and sharing with service providers
• Timely communication of payments to service providers and sharing statements.
• Timely and continuous reconciliations with service providers
• Manage benefit utilization and report on the same
• Recommend cover design to underwriter as a result of vetting
• Verify and review all medical claims invoices and provide recommendations on cover design aspects as a result of verification to Underwriting
• Processes documentation all medical claims for settlement and ensures claim files are signed promptly
• Share service provider remittances promptly and engage on reconciliation discussions to attain monthly sign-offs
• Resolve and process claims/invoices relating to outstanding/unpaid amounts to service providers
• Negotiates professional and procedure fees with service provider and ensure fess are within Medical Board rates
• Manages administration of outpatient self-funded schemes for specifically allocated schemes as well as benefit utilization management of the same ensuring reports are generated on a quarterly and annual basis to Claims Supervisor and scheme managers
• Gives feedback to underwriting on claims which require future intervention including prompt reporting on fraud cases, overpricing issues and over utilization and liaising with scheme manages and service providers
• Follows up recoveries from employers and insured for settlement paid on behalf
• Responsible for ensuring adherence to, implementation of, and adoption of Compliance, Anti-Money Laundering (AML), and Sanctions-related policies, procedures, and process requirements within Old Mutual and its subsidiaries. This includes execution of customer due diligence processes, ensuring compliance with Know-Your-Customer (KYC) standards, conducting ongoing and enhanced due diligence, and maintaining data quality. Additionally, the role involves identifying and monitoring potential AML, Sanctions, or Compliance breaches and unusual activities, and escalating these concerns to the Risk and Compliance Office for further action.
• Any other duties as maybe assigned.

Skills

Authentication, Communication, Computer Literacy, Customer Due Diligence (CDD), Customer Service, Documentations, Due Diligence, Enhanced Due Diligence, Ensure Compliance, Invoices, Know Your Customer (KYC), Management Reporting, Medical Claims, Medical Services, Office Administration, Payment Handling, People Management, Remittance Processing, Taking Initiative, Teamwork, Utilization Management, Vetting

Competencies

Decision QualityDirects WorkEnsures AccountabilityManages ComplexityOptimizes Work ProcessesPlans and AlignsTech Savvy

Education

Bachelors Degree (B): Medical Claims Assessing (Required), Bachelors Degree (B): Nursing (Required), Diploma (Dip): Medical Claims Assessing (Required)