Experience

Guardrisk

• South Africa
• Financial Services
• 200 - 300 Employee

• Claims Quality Assurer

  • Dec 2021 - Present

  • Receiving of finalised (pre-quality assured) claims automatically allocated from the system. • Accurately and completely reviewing the clinical details of each claim received on the same day or within 2 working days of receipt; • Quality assuring claims in accordance with practice guidelines, policy wording and protocols; • Ensuring that each claim that is incompletely / incorrectly processed is returned to the claims assessor within 24 hours of receipt; • Finalisation and forwarding of quality assured claims for approval / rejection; • Detecting and acting on potential fraudulent claims; • Ensuring a high level of service when liaising with individual and corporate customers, intermediaries, binder holders and colleagues; • Ensuring that the principles of TCF are delivered across every function performed, with a specific focus on the achievement of TCF Outcome 6 (Customers do not face unreasonable post-sale barriers to change product, switch provider, submit a claim or make a complaint). Show less



MEDSCHEME HOLDINGS

• South Africa
• Financial Services
• 400 - 500 Employee

• Support Agent

  • Dec 2018 - Nov 2021

  • Ensure that payments were processed at correct rate and against available benefits • Investigate all documentation, correct where required and link to member's records • Analyse and correct incorrect payments and identify reason for non-payment. Apply Quality Analysis checklist to processing of claims • Provide comprehensive and accurate feedback to clients • Identify system constraints and escalate accordingly • Assist in Call Centre/other areas when required • Ensure that quality control targets are met • Meet delivery objectives through working with other team members within and linked to the department / project • Resolve operational performance variations and problems and escalate unresolved issues to higher levels • Ensure delivery targets/objectives are met and operate in a supportive manner to achieve successful delivery Show less



Sirago Underwriting Managers

• South Africa
• Insurance
• 1 - 100 Employee

• Claims Administrator

  • May 2017 - Nov 2018

  • Ensure timely and accurate administration and processing of claims. • Support the Claims Manager in the delivery of an effective and efficient administration service. • Take inbound and make outbound calls according to claims enquiries, complaints or general claims. • Liaise with service providers and other stake holders to support the effective management of claims. • Where appropriate, assist in the review of claims. • Assist with necessary auditing and reviewing of internal and external claim files. • Provide input to underwriters during the review of existing Insured’s claims experience. • Comply with standards for timeliness of contact, follow-up and payments. • Prepare claims summaries and respond promptly to queries. • Identify and respond to requests for support and assistance. • Provide accurate daily/monthly statistics to Claims Manager. • Where necessary, produce and maintain spreadsheets, bordereaux and databases to enhance data presentation, analysis and storage. Show less



Agility

• South Africa
• Financial Services
• 1 - 100 Employee

• Client Care Consultant

  • Nov 2015 - Apr 2017

  Assist members, service providers and appointed brokers with membership, benefit and claim related queries. Provide accurate information to members and providers in line with the scheme protocols and policies Take ownership of queries received and follow up and provide members with feedback Adhere to TAT for all queries Adhere to quality standards with every member/ provider/ broker interaction Provide excellent customer service to internal and external clients Assist members, service providers and appointed brokers with membership, benefit and claim related queries. Provide accurate information to members and providers in line with the scheme protocols and policies Take ownership of queries received and follow up and provide members with feedback Adhere to TAT for all queries Adhere to quality standards with every member/ provider/ broker interaction Provide excellent customer service to internal and external clients



Council for Medical Schemes

• South Africa
• Public Health
• 1 - 100 Employee

• Administrator

  • Jul 2015 - Oct 2015

  Determination of jurisdiction in respect of complaints raised by beneficiaries. Determine whether the matter falls within the jurisdiction of Council for Medical Schemes; Refer those that fall outside the mandate of CMS to the relevant organizations; Registration of complaints: Electronic registration, scanning and appending of complaints, responses and correspondence; Request further particulars (such as membership number, name of scheme) from the complainants for the purpose of registration; Attending to telephonic enquiries: Provide guidance on the process of lodging complaints; Acknowledge receipt of complaints; Provide feedback/update on status of complaints to callers; Doctors (service providers) complaints: Refer complaint to schemes and copy doctors on the referral; Ensure that referred complaints are responded to within the prescribed timeframe; Monitor responses from schemes, administrators, brokers: Ensure that response are attached to their respective files and notify the Legal Adjudication Officers of responses received; Public Relations: Booking boardrooms and making other logistical arrangements for the Senior Manager and the team; Booking accommodation and travelling arrangements for the team; Administrative support: Dairy management for the Senior Manager. Compiling meeting packs, taking minutes during unit meetings and distributing minutes; and Financial control: Ordering of stationery and office equipment and distribution thereof. Show less



Metropolitan Health Group

• South Africa
• Health, Wellness & Fitness
• 700 & Above Employee

• HIV Programme Administrator

  • Feb 2013 - Jun 2015

  Assisting with all administration needs for the department such as filling, photocopying, scanning, faxing of documents as well as answering and directing calls.Resolve and manage admin related inbound calls.Accurately process HIV related claims ensuring the correct benefit is used and ensuring timely payment of providers.Handle members and service providers queries with regards to enrollment, treatment Deal with service providers and members that send claims and to ensure and facilitate effective processing of claims.Providing accurate information to members or doctors with respect to the HIVP.Ensure that applications for the programme are captured and archived correctly.Process correspondence and data related to HIVP.Contact and follow up enrolled members and service providers as directed by the HIVP team.Assist in the accurate compilation of correspondence of the HIVP.Maintain monthly updates on new programme participants and associated costs. Show less

• Client Services Consultant

  • Nov 2011 - Feb 2013

  Taking inbound calls from polmed members and providers.Capturing member’s details correctly on the system.Handling medical aid claims, benefit and membership queries Assessing and processing claims, ensuring that the correct benefit category is used. Escalating member’s queries to the relevant departments.



Momentum

• Midrand

• Telesales Consultant

  • May 2011 - Oct 2011

  Making outbound calls to clients to sell the Metropolitan life cover. Capture sales and client’s details on the system. Making outbound calls to clients to sell the Metropolitan life cover. Capture sales and client’s details on the system.