PMB Specialist
Core
Manage and resolve Pre-Existing Condition (PMB) claims for a healthcare technology and medical claims business by assessing eligibility, gathering clinical data, and challenging incorrect rejections.
Role type
Specialist Claims Administrator (PMB)
Builds
Medical scheme claims processing and regulatory compliance
Domain
Healthcare / Medical Insurance
Deliverable
client delivery
Required skills
PMB process knowledge, claims assessment, clinical data gathering, regulatory escalation, complaint management, analytical problem-solving, attention to detail
Preferred skills
Administrative qualification
Technologies
ICD-10 coding systems, medical scheme portals
Responsibilities
Take ownership of PMB claims for specialist review, assess claims against PMB requirements, obtain clinical notes and ICD-10 codes from providers, track scheme turnaround times, investigate payment differences, escalate unresolved matters to Principal Officers, prepare formal complaints to the Council for Medical Schemes