Zach

Dedicated and detail-oriented Call Centre Agent with experience in medical aid claims, benefit verification, and provider support, seeking to transition into a Medical Aid Claims Specialist role. Skilled in claims processing, interpreting benefit rules, resolving claim-related queries, and delivering exceptional customer service while meeting strict Service Level Agreements (SLAs). Possesses a strong understanding of medical aid schemes, tariffs, ICD-10 coding, and healthcare administration, with a commitment to accuracy, compliance, and continuous professional development.

Eager to leverage analytical and problem-solving skills to contribute to efficient claims management and enhanced client satisfaction.

Customer Service Agent / Call Centre Agent (GEMS – Contracted via Momentum) at Momentum (2024-05 – Present)

Progressed from Work Readiness Learnership to top-performing Call Centre Agent within GEMS provider support environment.

• Consistently met and exceeded call centre KPIs, receiving recognition from stakeholders and management.
• Assisted healthcare providers with medical aid claims processing and member benefit confirmations.
• Investigated claim rejections and validated cases for reprocessing in line with scheme rules.
• Applied medical scheme billing rules and guidelines to ensure accurate claims adjudication.
• Identified, analysed, and resolved claim discrepancies and processing errors.
• Liaised with internal departments (claims back office and clinical teams) to resolve outstanding or complex claims.
• Worked within strict turnaround times and service level agreements (SLAs).
• Interpreted medical scheme tariff structures and reimbursement rates to assess claim outcomes.
• Compared provider billing against scheme tariffs to identify shortfalls and discrepancies.
• Clearly explained co-payments, deductibles, and member liability to healthcare providers.
• Identified out-of-network charges and explained their impact on claim payments.
• Demonstrated strong understanding of ICD-10 coding and its role in claims assessment.
• Analysed diagnosis codes for alignment with procedures and identified mismatches affecting claims.
• Recognised coding issues that could lead to claim rejections or reduced benefits.
• Applied knowledge of Prescribed Minimum Benefits (PMBs), including DTP/CDL lists, in claims evaluation.
• Assessed eligibility and criteria for PMB review and authorisation requirements.
• Interpreted the impact of authorisations on benefit payouts and claim settlement.
• Differentiated between network and non-network providers and applied relevant rules.
• Communicated scheme protocols for both in-hospital and out-of-hospital claims.
• Maintained up-to-date knowledge of tariffs, coding updates, and scheme benefit changes.
• Understood provider contract rates and identified scenarios where shortfalls are not member liable.
• Accurately routed claims to appropriate departments based on rejection reasons.
• Interpreted clinical rejections, including time-based billing limitations and tariff rules.
• Processed and resolved medical aid claims in accordance with scheme rules, industry legislation, and company policies.
• Investigated and adjudicated claims accurately, ensuring compliance with benefit structures, tariffs, and coding requirements.
• Assisted healthcare providers and members with claims enquiries, benefit confirmations, and payment-related queries.
• Interpreted and applied ICD-10, CPT/NAPPI, and tariff codes to assess claim validity and reimbursement eligibility.
• Identified claim rejections and provided clear explanations and corrective guidance to providers and members.
• Ensured first-call resolution of claims and benefit enquiries while maintaining high customer satisfaction levels.
• Managed high volumes of inbound calls and electronic queries while consistently meeting Service Level Agreements (SLAs).
• Escalated complex claims and authorisation issues to relevant departments for timely resolution.
• Maintained accurate records of client interactions, claim updates, and case notes across multiple systems.
• Liaised with internal departments, healthcare providers, and stakeholders to resolve outstanding claims efficiently.
• Identified operational risks and escalated potential fraud, irregularities, or compliance concerns in accordance with company procedures.
• Delivered exceptional client service by providing accurate, professional, and timely claims support.
• Built and maintained strong relationships with healthcare providers, members, and internal stakeholders.
• Contributed to continuous process improvement by identifying opportunities to enhance operational efficiency and service delivery.
• Ensured compliance with medical scheme legislation, POPIA requirements, and internal governance policies.
• Demonstrated strong knowledge of medical aid benefits, authorisations, exclusions, protocols, and reimbursement policies.
• Achieved departmental productivity and quality assurance targets while maintaining accuracy and attention to detail.
• Participated in training initiatives to remain current on industry legislation, benefit changes, and claims processing procedures.
• Collaborated effectively within cross-functional teams to improve claims turnaround times and client satisfaction.
• Consistently demonstrated professionalism, accountability, problem-solving ability, and a results-driven approach in a fast-paced call centre environment.

High School – Rosendaal High School (2021)