Senior Claims Administrator

We are seeking a Senior Claims Administrator with strong clinical background to join our team.Qualifications: Clinical or Nursing Diploma/Degree.SANC Registered.FAIS Compliant (advantageous).Skills and Experience: At least 2 – 3 years’ gap cover claims experience.Technical knowledge of various health insurance products.Advanced knowledge of ICD Codes, medical procedures, and medical aid schemes.Sound understanding of Prescribed Minimum Benefits (PMB) legislation in conjunction with gap cover.Experience in dealing with escalated and/or complex claims.Strong computer skills, including Microsoft Office and intermediate to advanced Excel.Excellent customer service, communication, and interpersonal skills. Advanced Business English (written and verbal).Strong attention to detail and accuracy.Analytical and problem-solving skills with the ability to interpret clinical information.Ability to take ownership and responsibility for actions and outcomes.Ability to handle pressure while remaining calm, professional, courteous, and solution oriented.Ability to work independently and as part of a team.Ability to prioritise tasks effectively in a fast-paced environment.Strong organisational and time management skills.Sound ethical judgment and integrity, ensuring compliance with internal policies and regulatory standards. Demonstrate continuous learning mindset with a willingness to stay current on clinical advancements and industry changes.Reporting to: Claims SupervisorScope of responsibility: Authorise assessed claims in accordance with policy rules, benefits, and conditions.Conduct clinical review and validation of pre-existing conditions and casualty claims.Attend to escalated and complex clinical queries.Respond to broker and policyholder queries in a timely and professional manner.Ensure compliance with internal policies, procedures, and regulatory requirements.Maintain accurate records and documentation of claims assessments and outcomes.Contribute to process improvement initiatives within the claims department.Any other duties as assigned by the company from time to time.Changes: The company reserves the right to change this job description at its sole discretion from time to time.Applications: hr@ambledown.co.za