Job Summary: We are seeking a knowledgeable and detail-oriented Medical Claims Specialist to manage and process medical claims efficiently. The ideal candidate will have in-depth knowledge of PMB (Prescribed Minimum Benefits) rates and the medical claim life cycle. They will be responsible for ensuring accurate claim submissions, monitoring timelines, processing payments, and reconciling remittances and bank statements. This role is essential in facilitating prompt claim processing and efficient handling of payment allocations.
Key Responsibilities:
- Review and apply PMB rates and payments in alignment with relevant policies and guidelines.
- Accurately interpret and utilize medical procedure codes, billing codes, and applicable modifiers.
- Maintain proficiency in ICD-10 coding and morphology coding for accurate claim submission.
- Oversee and manage the complete claim life cycle from submission to resolution.
- Navigate and understand medical schemes, including submission timelines, claim inquiry processes, and payment contracts.
Qualifications and Skills:
- Proven experience in medical claims processing or a related field.
- Strong understanding of PMB rates, ICD-10, and morphology codes.
- Knowledge of procedure codes, including billing guidelines and applicable modifiers.
- Familiarity with medical scheme policies, submission timelines, and payment procedures.
- Proficiency in claims life cycle management and crediting knowledge.
- Ability to analyze and reconcile remittance statements and bank statements.
- Excellent organizational skills and attention to detail.
- Strong communication skills for interaction with internal and external stakeholders.
- Able to provide training to 30 staff members.
- Team player and open to constructive criticism.
Preferred Qualifications:
- Experience working with medical schemes or health insurance providers.
Job Type: Full-time
Pay: R10,000.00 - R20,000.00 per month
Ability to commute/relocate:
- Johannesburg, Gauteng: Reliably commute or planning to relocate before starting work (Preferred).
Application Deadline: 2024/11/20
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