Prescribed Minimum Benefit (PMB) Specialist
Core
Own the end-to-end Prescribed Minimum Benefit (PMB) claims process to ensure legislative compliance and secure rightful reimbursement for medical practices.
Role type
Claims specialist (health insurance)
Builds
Funded medical claims for practices
Domain
Health insurance / Medical schemes
Deliverable
client delivery
Required skills
PMB process knowledge, claims administration, clinical documentation review, regulatory escalation, formal complaint preparation
Preferred skills
None stated
Technologies
None stated
Responsibilities
Intercept and take ownership of flagged PMB claims; Complete and submit PMB application forms and scheme-specific documentation; Liaise with surgeons and providers to obtain clinical notes and ICD-10 codes; Execute follow-ups on PMB escalations to meet scheme review periods; Escalate unresolved disputes to scheme Principal Officers; Prepare and lodge formal complaints with the Council for Medical Schemes (CMS)
Seniority
Mid-level, hands-on specialist