The Claims Process Owner is responsible for the end-to-end ownership, governance and optimisation of PPO Serve’s monthly claims process. While core processes are largely automated (or being automated), this role ensures data integrity, process efficiency, stakeholder alignment and timely, accurate claims delivery. The Claims Process Owner acts as the central point of coordination between PPO analytics, finance, operations and external stakeholders (actuaries and other service providers).
End- to End Claims Process Ownership
- Own the full monthly claims cycle from data receipt to payments to doctors
- Oversee and audit automated pipelines for claims generation and validation
- Ensure adherence to documented methodologies for claims inclusion and payment models
- Manage timelines, dependencies and critical deadlines
Data Governance & Quality Control
- Oversee provider file management in collaboration with PPO Sales
- Validate outputs from internal and external membership files
- Perform quality control checks on membership files throughout the claims cycle
- Investigate and resolve data discrepancies at line level where required
- Prepare month-end reconciliation report
Automation & Continuous Improvement
- Support migration and optimisation of claims processes within PPO Serve’s data platform
- Identify process risks, inefficiencies and control gaps
- Maintain clear process documentation and audit trails
Stakeholder Engagement & Issue Resolution
- Primary point of contact for all claim-related queries – internal (doctors, coaches, finance) and external (actuaries, medical schemes)
- Proactive communication regarding risks, delays or discrepancies
Skills & Compentencies
- Strong process management and governance capability
- High attention to detail and data integrity
- Analytical problem-solving ability
- Stakeholder management and communication skills
- Ability to operate within automated data environments
Technical Requirements
- Advanced Excel
- Working knowledge of Power BI
- Experience managing data pipelines and structured data exchanges is advantageous
Qualifications & Experience
- Business-related degree or equivalent
- Minimum 5 years’ experience in Bookkeeping, Business Analyst, Claims, or Scheme-related role
- Experience within a medical scheme or healthcare funding environment preferred
WHAT WE OFFER
- Opportunity to make a significant impact on real-world healthcare challenges.
- Be part of a collaborative, innovative, and data-driven culture.
- Competitive market-related salary.
- Opportunities for professional growth and continuous learning with cutting-edge technologies.
- A commitment to work-life balance and a supportive team environment.
* IF WE HAVE NOT CONTACTED YOU 14 DAYS PLEASE CONSIDER YOUR APPLICATION UNSUCCESSFUL*
Work Location: Hybrid remote in Alberton, Gauteng
