Claim Submission Specialist x9

Function

Other

Facility

Cape Town Regional Office

Position

Claim Submission Specialist x9

Introduction

Vacancies exist for Nine Claim Submission Specialist based at the Cape Town Regional Office, reporting to the Team Lead – Claim Submission Specialist. The successful candidate will manage the initial stages of the claims process as well as any rejections. The job exists to ensure that claims are accurately submitted and processed, facilitating timely and fair settlements.

Critical Outputs

Ensuring the appropriate optimisation of revenue

• Accurate billing and funder contract interpretation:
• Ensure accurate and complete coding of patient accounts was done by the Case Manager.
• Ensure the correct application and correct interpretation of funder contracts.
• Ensure the correct application and correct interpretation of funder FFS claims.
• Report on alerts RSRT risks identified to manager.
• Identify and monitor gaps and risks and assist with the implementation of corrective actions.

Ensuring effective management of quality outputs

• Achieve QMS target:
• Adherence to ISO  9001 standards.
• Adherence to patient services policies, procedures and escalation processes.
• Process alerts and incidents identified during the case management process.
• Drive adherence to customer service standards.
• Identify and monitor gaps and risks and assist with the implementation of corrective actions agreed with management.
• Comply with governance and risk management requirements:
• Understand and ensure adherence to patient services
• Comply to service level agreements with internal and external stakeholders.
• Identify and monitor gaps and risks and assist with the implementation of corrective actions.
• Perform line-by-line validation of accounts prior to submission
• Check Length of stay (LOS), Level of care (LOC), Billing methods and modifiers, System and configuration accuracy
• Identify errors or missing information and refer cases to the allocated Case Manager for correction

Ensuring operational excellence

• Meet Patient Services case management targets:
• Ensure case was updated and approved in full by the funder before all billing checks was closed.
• Refer cases not fully approved back to the allocated Case Manager.
• Ensure effective management of real time and manual messaging, including requests, responses, rejections and submissions.
• Ensure the accurate submission of accounts to funders.
• Ensure the claims workflow failed screen is managed.
• Ensure End-to-End Claim Processing
• Ensure claims from Bill Ready to Final Billed status
• Ensure 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)

Manage System Monitoring & Exception Handling

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

Ensuring effective management of relationships with internal/external stakeholders

• Productive relationships with internal stakeholders:
• Foster and maintain healthy relationships with internal stakeholders. E.g. nursing, pharmacy and business hubs.
• Provide relevant feedback and information on concerns or issues raised by internal stakeholders.
• Identify and monitor gaps and risks and assist with the implementation of corrective actions agreed with management.
• Productive relationships with external stakeholders:
• Provide relevant feedback and information on concerns or issues raised by external stakeholders.
• Provide feedback on external stakeholders impacting on the efficiency and effectiveness of the submission process.
• Escalate doctor non-compliance in terms of RSRT framework.

Requirements

• Diploma or degree in Nursing, Physiotherapy, Clinical Associates, Paramedics as Critical Care Assistants or Emergency Care Practitioners or any other qualification that covers Anatomy, Physiology, Pathophysiology and Microbiology as foundational courses. Experience including proven leadership, change 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 and understanding of CPT & ICD coding
• Knowledge of Funder contracts, scheme rules, exclusions and benefits
• Understanding of private hospital industry and practices
• Computer proficiency
• Valid driver’s license

Competencies

• Attention to detail
• Problem-solving, analysis and judgement
• Resilience
• Engaging diversity
• Verbal & written communication skills
• Professional and technical proficiency
• Interpersonal and relationship building skill
• 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