PMB Specialist
Core
Specialist review of medical claims to determine eligibility for Pre-Existing Condition (PMB) coverage under medical schemes.
Role type
Specialist Claims Analyst (Healthcare/Medical Schemes)
Builds
Medical scheme claims adjudication and regulatory compliance
Domain
Healthcare / Medical Insurance
Deliverable
client delivery
Required skills
PMB process knowledge, claims assessment, clinical note analysis, regulatory escalation, complaint management, analytical problem-solving, attention to detail
Preferred skills
Administrative qualification
Technologies
ICD-10 coding systems
Responsibilities
Assess claims against PMB requirements and return non-qualifying cases, obtain clinical notes and ICD-10 codes from providers, track scheme turnaround times, investigate payment differences and challenge incorrect rejections, escalate unresolved matters to Principal Officers, prepare formal complaints to the Council for Medical Schemes