PMB Specialist
Core
Review and adjudicate Pre-Existing Condition (PMB) medical claims, ensuring compliance with scheme requirements and resolving payment discrepancies.
Role type
Specialist medical claims adjudicator
Builds
Accurate claim decisions and resolved payment issues for medical schemes
Domain
Healthcare administration / Medical insurance
Deliverable
client delivery
Required skills
PMB process knowledge, claims assessment, clinical note analysis, regulatory escalation, complaint management, data tracking
Preferred skills
Administrative qualification, analytical problem-solving, attention to detail
Technologies
ICD-10 coding systems, claims management software
Responsibilities
Assess claims against PMB requirements and return non-qualifying cases, obtain clinical notes and ICD-10 codes from healthcare providers, track scheme turnaround times and follow up on expiring reviews, investigate payment differences and challenge incorrect rejections, prepare and manage formal complaints to the Council for Medical Schemes
Seniority
Junior to Mid-level, hands-on specialist