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Manager Medical

Location:
Johannesburg, Gauteng, South Africa
Posted:
July 30, 2020

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Resume:

OBJECTIVE

To work in an environment which

encourages me to succeed and grow

professionally where I can utilize my skills

and knowledge appropriately.

PERSONAL DETAILS

Date of Birth : 15/02/1986

Marital Status : Single

Nationality : South African

Claims Investigator :

EDUCATION

UNISA

2015

COIDA

NQF5

Reservoir Hills Secondary High

2003

Matric

Exemption

REFERENCE

Michelle Govender - "Constantia Insurance"

Senior Operations Manager

adeyzl@r.postjobfree.com

083-***-****

Karabo Muaone - "FEM"

Claims Manager

adeyzl@r.postjobfree.com

082-***-****

SKILLS

Time management, report writing, TCF, Team

work, Computer proficient

EXPERIENCE

ROXANNE ARUMUGAM

adeyzl@r.postjobfree.com

076*******

The Louries Fontein and Perm Street Sonneglans Randburg Roxanne Arumugam

Constantia Insurance

01 November 2019 - 31 May 2020

Claims Investigator

.Responsible for all activities pertaining to

Medical Claims and Claims assessing in terms of

Individual, Group Risk and Employee Benefit

products/ policies

· Maintaining turnaround times in terms of

service level agreements for the processing and

assessment of claims within prescribed times

· Full and accurate intimation of death,

disability and critical illness claims

· Preparation of claim with all required

documents as indicated by claim type ensuring

minimum requirements are adhered to prior to

assessing the claim

· Accurate updating of the claim status and

data relating to each claim on related business

system

· Follow up of outstanding requirements with

claimant as required in order to finalise a claim

· Collating of all relevant documentation

including an investigation report of EX gratia claim prior to sending to Management for approval and

payment

· Maintaining professional written

communication with claimant using approved

company templates

· Identifying and flagging fraudulent claims

and updating the RED list

· Adhering to life claims principles and

philosophies

· Maintain claims standards operating

procedures

· Document and highlight all concerns with

clients at regular monthly meeting with a solution orientated approach

· Where applicable attend monthly SAICB

meetings and provide feedback to team

· Ensure data integrity of claims information

for management reporting purposes

Assisting with telephonic queries

Scanning, emailing, etc

FEM

01 April 2011 - 31 March 2018

Medical Claims Assessor

. Registration of new I.O.D’s.

. Handling of all telephonic enquiries.

. Allocating of documents to claim numbers onto

the profem system.

. Indexing of documents on the profem system via

correct allocation of claim numbers.

. Scanning of documents onto profem via correct

allocation of claim numbers.

. Request all relevant documents to allocate to

claim to ensure a faster payout time period.

. Duplicate checking of documents.

. Destroying of documents on profem as well as

manual.

. Data capturing.

. Sorting of documents and allocation of claim

numbers.

. Assistance with remittance as well as other

payment enquiries.

. Ensuring that all new claims have the correct

information, correct documents and completion

of all questions.

. Assisting Reception.

. Full internal claims Assessor training (Coida Act 1993)

. Payment of medical accounts and refunds to the

employee and employer.

. Follow up on claim process

. Requesting medical reports from service

providers

. Calculating Permanent disability awards to pay

out to injured employees based on the medical

reports from the specialist or general practioner.

. Calculating monthly wages according to the

COID ACT

. Estimating the total cost of a claim.

. Finalization of claims

. Filing, Faxing, Emailing, etc.



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