CIMAS
DUE: 30 MAR 2023
THE ROLE
Receives claims from Sorting Office and processes claims for the relevant sections daily i.e., Drugs, Dental, Radiology, Pathology, Specialists, Optical, Medical, General Practitioners, Industrial/Municipal Clinics, Government/Mission/Private hospitals, and Foreign Claims from Supervisors. Checks claims for completeness and correctness and refers complicated cases to Team Leads.
Identifies anomalies i.e., fraudulent and risky claims from members and service providers and refers to the Team Lead for investigation.
Processes claims routed in work bins – checking quantities, diagnoses against tariffs and applies adjudication rules correctly.
Reprocesses adjusted or amended claims with errors when necessary.
Returns provider claims with insufficient details/documents on the system.
Reports system errors picked up during assessing to the Team Lead for logging with IT department or for escalation to Management.
Records daily statistics from the system.
Records and files daily submission case notes to the Team Leads
THE PERSON
Minimum qualification must be a Diploma in Nursing.
Must possess 3 or more years of practising experience and a valid practising licence.
Good communication skills and good knowledge of office procedures and practices.
An energetic, organized individual with excellent interpersonal skills and the ability to cope with pressure under minimum supervision.