Cynthia Phillips
Claims specialist | medical claims assessor | healthcare administration professional | Admin Clerk | Data Capturer
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About
Highly experienced and detail-oriented Claims Specialist and Medical Claims Assessor with over 30 years of experience in the healthcare and medical aid industry. Proven expertise in claims adjudication, claims administration, medical coding interpretation, fraud detection, customer service, and healthcare compliance. Demonstrated ability to assess complex medical claims, ensure accurate claim processing, maintain strict confidentiality, and support organisational objectives through sound decision-making and exceptional analytical skills.
Recognised for maintaining high levels of accuracy, meeting service level agreements, and providing expert guidance on complex and high-value claims.
Experience
Claims Specialist at LIBERTY HEALTH (2005-01 – 2026-05)
- Assessed and adjudicated complex medical claims by reviewing clinical, financial, and policy documentation to ensure accurate benefit allocation.
- Evaluated high-risk and high-value claims in accordance with Standard Operating Procedures (SOPs), company policies, and healthcare regulations.
- Provided specialist advice and technical support to management on complex, contentious, and escalated claims cases.
- Collaborated with healthcare providers, service providers, and legal representatives to investigate fraud, waste, abuse, and disputed claims.
- Monitored claims workflows and processing queues to ensure turnaround times and service level agreements (SLAs) were consistently achieved.
- Resolved escalated claims enquiries and disputes while maintaining a strong focus on customer service and client satisfaction.
- Captured and processed high volumes of medical claims, member information, and medical coding data with exceptional accuracy.
- Verified and audited claims documentation to ensure completeness, compliance, and eligibility prior to processing.
- Investigated and resolved outstanding claims queries through effective engagement with members, brokers, and healthcare practitioners.
- Compiled management reports, maintained confidential records, and supported operational efficiency through accurate data administration and record management.
Claims Processor at BANKMED (1998-01 – 2004-01)
- Processed and assessed medical aid claims according to scheme rules and healthcare policies.
- Managed member queries regarding claims submissions and benefits.
- Captured and verified claims data with accuracy and efficiency.
- Assisted healthcare service providers with claims-related enquiries.
- Ensured compliance with healthcare regulations and company procedures.
- Maintained accurate claim records and documentation.
Claims Administrator at SANLAM (1995-01 – 1998-01)
- Processed healthcare-related claims documentation.
- Captured and maintained policyholder and claims information.
- Assisted clients with claims enquiries and status updates.
- Verified supporting documentation and ensured regulatory compliance.
- Supported administrative operations within the claims department.
Education
Senior Certificate in Grade 12 – Kleinvlei Secondary School (1991-01)
