Location: Centurion, Gauteng

Position Purpose: The Claims Team Leader is responsible for overseeing the daily operations of the claims processing team, ensuring that claims are assessed, processed, and paid accurately, efficiently, and in line with the policies, guidelines of the medical aid scheme and service level agreements (SLAs). The role also focuses on managing the financial risk associated with claims, enhancing the quality of service to members, and protecting the sustainability of the medical aid scheme.

 Experience:  At least 1–2 years’ experience in a supervisory or team lead role.

 Qualifications:

• Matric (Grade 12)
• Relevant qualifications in Healthcare Administration, Business Management, or related field (advantageous).

  KEY PERFORMANCE AREAS

  Claims Processing

• Supervise the day-to-day operations of the claims department team.
• Ensure timely and accurate processing of medical aid claims in accordance with scheme rules.
• Review and authorize high-value or complex claims.
• Monitor and manage claim adjustments, denials, and appeals.

 Team Management

• Supervise, mentor, and evaluate the performance of claims staff.
• Provide training and support to ensure staff adherence to policies and procedures.
• Conduct regular team meetings to discuss performance, updates, and best practices.
• Plan and implement daily, weekly and/or quarterly operational changes within the team to respond to important external influences
• Ensure implementation of work plans in a way that maintains operational best practice and leads to continuous delivery improvement

 Compliance and Quality Assurance

• Ensure all claims are processed in compliance with scheme rules.
• Implement and maintain quality control procedures to minimize errors and fraud.
• Stay updated on changes in healthcare regulations and claim processing guidelines.

 Stakeholder Engagement:

• Handle escalated customer inquiries and complaints with professionalism and efficiency.
• Work closely with policyholders, healthcare providers, and other stakeholders to resolve issues and provide clear explanations of claim decisions.

• Act as the primary point of contact for escalations from internal and external stakeholders.
• Liaise with providers, brokers, and members regarding queries and complaints.
• Collaborate with other departments (e.g., Clinical, Finance, IT) to resolve issues and improve processes.

  Reporting and Analysis:

• Prepare and present daily, weekly, and monthly performance reports.
• Analyse claims data to identify trends, risks, and opportunities for improvement.
• Provide insights and recommendations to management.

 Process Improvement:

• Identify opportunities to streamline workflows and improve efficiency.
• Support system enhancements and process changes.
• Ensure implementation of best practices in claims management.

• Collaborate with IT and other departments to integrate new technologies and systems

KEY COMPETENCIES

  Skills and Abilities

 Strong leadership and people management skills.

• In-depth knowledge of claims processing, PMB regulations, and healthcare industry practices
• Excellent attention to detail, analytical and problem-solving abilities.
• Strong communication and interpersonal skills.
• Proficiency in claims management software and Microsoft Office Suite (Excel, Word, PowerPoint).
• Attention to accuracy and detail.
• Ability to work under pressure and meet deadlines

 Knowledge

• Knowledge and application of relevant legislation
• Knowledge and application of scheme rules

Note: Company reserves the right to close the advert before specified closing date.