About the Role

We are looking for a detail-oriented and analytical Medical Claims Assessor to review and process medical aid or health insurance claims accurately and efficiently. You will evaluate claims against policy terms, medical guidelines, and regulatory requirements while ensuring excellent service to members and healthcare providers.

What You'll Do

Assess and process medical claims in accordance with company policies and benefit rules
Review medical documentation and supporting evidence for claim accuracy
Verify claim eligibility, coding, and coverage details
Approve, decline, or refer claims based on policy guidelines and clinical criteria
Liaise with healthcare providers, members, and internal departments to resolve claim queries
Investigate discrepancies and identify potential fraudulent claims
Maintain accurate records of claims assessments and decisions
Ensure compliance with healthcare regulations, company policies, and industry standards

Requirements

Diploma or Degree in Healthcare Administration, Nursing, Medical Coding, Health Sciences, or a related field (preferred)
Previous experience in medical claims, medical aid administration, or health insurance is advantageous
Knowledge of medical terminology, ICD coding, and healthcare funding processes is preferred
Strong analytical and problem-solving skills
Excellent attention to detail and organisational abilities
Proficiency in Microsoft Office and claims management systems

Key Skills

✔ Medical Claims Assessment

✔ Medical Terminology

✔ Claims Processing

✔ Healthcare Regulations

✔ Data Analysis & Reporting

✔ Attention to Detail

✔ Communication & Customer Service