Clinical Claims Adjudicator Johannesburg CBD

📌 OPPORTUNITY OVERVIEW:-Rand Mutual Admin Services is actively recruiting for a Clinical Claims Adjudicator position in Johannesburg CBD. This is an excellent opportunity for professionals in the Insurance sector looking to advance their careers.

🎯 IDEAL CANDIDATE PROFILE:-We are seeking talented individuals with the following profile:• Experience Level: 5 - 10 years • Educational Background: Bachelor or equivalent• Industry Focus: Insurance• Location Preference: in Johannesburg CBD

💼 WHY THIS ROLE MATTERS:-The Clinical Claims Adjudicator position is an important role within the Insurance sector, offering meaningful career development and professional growth opportunities.

📈 CAREER DEVELOPMENT INSIGHTS:-With 5-10 years in Insurance, you're positioned for senior roles. This opportunity allows you to mentor others and drive strategic initiatives.

📋 APPLICATION GUIDANCE:-When applying for this Clinical Claims Adjudicator position, ensure your CV highlights:• Relevant experience matching the 5 - 10 years requirement• Educational qualifications in line with Bachelor• Specific achievements in the Insurance field• Any certifications or specialized training

🌍 SOUTH AFRICA JOB MARKET CONTEXT:-The Insurance sector in South Africa continues to show strong demand for skilled professionals. This position represents a valuable opportunity in the current job market.

Vacancy Details Employer: Rand Mutual Admin Services

Introduction: The Clinical Claims Adjudicator position operates under the Team Leader: Clinical Claims Adjudication. The role involves supporting the effective and efficient adjudication of disease and accident claims, in accordance with COID Act and Non-COID VAPS policies.

Description: As the Clinical Claims Adjudicator, you will be responsible for supporting the adjudication of disease and accident claims within the Insurance sector. Your duties include reviewing and updating ICD10 codes, liaising with medical service providers to submit outstanding medical reports, evaluating treatment authorizations, managing costs associated with authorizations and claims estimates, assessing claims nearing Maximum Medical Improvement (MMI), adjudicating permanent disability, and referring disease claims to medical advisors.

Claims Processing and Adjudication: Your responsibilities will include reviewing and updating ICD10 codes, reviewing medical reports and medical investigation reports on the system, liaising with medical service providers for outstanding medical reports, evaluating treatment authorizations, managing costs, assessing claims nearing MMI, adjudicating permanent disability, and referring disease claims to medical advisors.

Medical Report Writing: You will be required to triangulate and summarize medical information to refer claims to medical advisors and/or Technical Committee for decisions on extension of MMI or impairment assessment.

Requirements: To be successful in this role, you must possess an NQF Level 7: Degree in Health Sciences, postgraduate diploma in occupational health (advantageous), RE5 Certificate (essential), 3-5 years of experience in in-hospital clinical/case management/medical aid claims environment, Group Life Insurance experience (advantageous), and Occupational Health experience (essential). You must also have clinical judgement, knowledge of ICD10, MS Office, COID Act and its instructions, Occupational Health and Safety Act, AMA Guide, disability impairment assessment, claims case management, stakeholder engagement, communication skills, and knowledge of business policies, processes, and procedures.

Our Commitment to Transformation: Rand Mutual Admin Services values diversity and will consider preference for candidates from under-represented designated groups, in line with the employment equity plan.