Claim Submission Specialist Team Lead

Function

Other

Facility

Cape Town Regional Office

Position

Claim Submission Specialist Team Lead

Introduction

A vacancy exists for a Team Lead – Claim Submission Specialist, based at our Cape Town Regional office reporting to the National Case Manager.

The successful candidate will be responsible for leading and managing a team of Claim Submission Specialists to ensure optimal claims submission, revenue realisation, and quality performance. The role focuses on driving operational excellence, compliance, efficiency, and stakeholder satisfaction within the claim’s submission function.

Critical Outputs

Ensuring the appropriate optimisation of revenue:

• Ensure accurate and complete claim submission and optimal funder contract interpretation
• Monitor billing accuracy, coding quality, and claim completeness
• Oversee management of rejections, short payments, and escalations
• Analyse revenue cycle reports (e.g. DNFB, DSO, coding audits) and implement improvements
• Identify revenue risks, gaps, and opportunities and implement corrective actions
• Drive improvement in clean claim rates and reduce revenue leakage

Ensuring operational excellence:

• Lead and manage day-to-day operations of the claim submission team
• Monitor workflow management, including real-time messaging, submissions, and rejections
• Ensure adherence to patient services policies, procedures, and SLAs
• Manage workload distribution, productivity, and turnaround times
• Identify operational inefficiencies and drive continuous improvement initiatives
• Ensure compliance with governance, risk, and audit requirements
• Manage End-to-End Claim Processing
• Manage claims from Bill Ready to Final Billed status
• Manage initial claims and amended claims where required
• Continuously monitor claims that fail or reject and rework them until resolved
• Work across multiple system statuses (e.g. rejected, failed, integration errors)

Ensuring effective management of quality and compliance:

• Ensure adherence to QMS, ISO standards, and internal audit requirements
• Monitor audit outcomes, coding accuracy, and compliance metrics
• Drive a culture of quality, accuracy, and continuous improvement
• Ensure adherence to escalation processes and quality standards
• Manage line-by-line validation of accounts prior to submission
• Manage Quality Assurance of team on checking Length of stay (LOS), Level of care (LOC), Billing methods and modifiers, System and configuration accuracy
• Manage identification of errors or missing information and ensure process followed to refer cases to the allocated Case Manager for correction

Manage System Monitoring & Exception Handling

• Monitor dashboards and reports (e.g. DNFB, Finalise a Bill)
• Manage the Follow up of Claims >24 hours in a status, Failed integrations, Outstanding billing processes
• Ensure no claim remains unresolved in the workflow

Reporting and Trend Identification

• Track patterns in rejections and failures
• Provide feedback on common errors, System issues and Process gaps

Ensuring effective people leadership:

• Lead, coach, and develop Claim Submission Specialists
• Set performance expectations and manage team KPIs
• Conduct performance reviews and address underperformance
• Drive team engagement, accountability, and motivation
• Support change management and adoption of new processes and systems
• Ensure ongoing training and upskilling of team members

Ensuring effective stakeholder management:

• Build and maintain strong relationships with internal stakeholders (case management, nursing, finance, pharmacy)
• Engage effectively with external stakeholders (funders and doctors)
• Manage and escalate stakeholder issues impacting claim submission
• Provide feedback on systemic challenges affecting efficiency and revenue
• Facilitate communication and training on funder requirements and processes

Requirements

• Nursing Qualification, preferably Professional Nurse with at least 5 years’ experience
• Proven case manager and clinical coding experience of at least 5 years.
• Proven experience in leadership, change management, and people management
• Current registration with the relevant professional/regulatory body (South African Nursing Council)
• Knowledge of hospital patient services and case management processes
• Knowledge of CPT & ICD coding and clinical terminology
• Understanding of funder rules, contracts, co-payments, exclusions, and benefits
• Knowledge of hospital billing systems and processes
• Computer proficiency

Competencies

• Attention to detail
• Problem-solving, analysis and judgement
• Resilience
• Engaging diversity
• Verbal & written communication skills
• Professional and technical proficiency
• Building relationships
• Customer responsiveness
• Organisational awareness
• Influencing skills
• Action orientation
• Excellence orientation
• Ethical behaviour
• Drive and energy

Email

careers@lifehealthcare.co.za

Closing date

Friday, June 12, 2026