Work experience

• KEYHEALTH CLAIMS CONSULTANT

  PPSHA

  2021.01-Current

  (5 years)

  • Pay attention to detail to reconcile member or provider claims received using Medical Aid MSO System and ISO System. • Send out previously paid claims for reversals as requested by the member or provider. • Ensure compliance with schemes Service Level Agreement (SLA) and rules as required. • Send out workflows to Authorization Department to update member authorizations.
• DISEASE RISK MANAGEMENT CONSULTANT

  TEMP, PPSHA

  2020.01-2021.01

  (a year)

  (PROFESSIONALPROVIDENT SOCIETY HEALTHCARE ADMINISTRATORS) • Utilized clinical knowledge and good clinical practice to capture RFMCF (Regular ForceMedical Continuation Fund) member information on administrative system. • Chronic disease monitoring for disease risk management using good clinical practice guidelines and generating treatment plans. • Indexed treatment plan documents for availability of authorisations. • Established regular lines of communication by Sending out RFMCF, KeyHealth and Profmed Medical Aid Scheme Correspondence to both members and providers to manage ongoing project expectations and issues. • Loaded Authorizations for clients on the Medical Aid System. • Applied medical scheme knowledge and kept effective relationship between members, providers and the medical aid schemes while developing a deepened relationship to increase loyalty and brand engagement. • Generated and resolved data query and follow up letters. • Managed the progress of disease risk management by drawing and tracking monthly departmental case report stats and sending them to the PPSHA company executives and leadership.
• RFMCF CLAIMS CONSULTANT

  TEMP, PPSHA

  2019.01-2020.01

  (a year)

  • Analyzed, reconciled, and processed information on claims account both qualitatively and quantitatively. • Used IDC10 Coding System and Medical Aid rules and regulations to process claims received from both members and Providers. • Assessed claims received electronically, via paper, or through fax or email in the Medical Aid MSO System and ISO System. • Completed reversals as requested by members, providers, or third parties. • Escalated requests for corrections to relevant consultants. • Followed up and resolved routed enquiries.
• WELLNESS ASSISTANT

  CLICKS RETAILERS (PTY) LTD

  2018.01-2019.01

  (a year)

  • Provided excellent customer service by approaching customers and answering sensitive health questions to ensure enhancement on clinical health. • Researched about different health topics by attending workshops, creating and assisting with development of health education materials within the shop. • Gave feedback to customer queries about stock availability via telephonic calls. • Monitored stock availability and doing stock-taking to provide an audit of existing stock to management.

Projects

• RFMCF Disease Risk Management

  Disease Risk Management Consultant

  2020.01-2021.01

  (a year)

  (PROFESSIONALPROVIDENT SOCIETY HEALTHCARE ADMINISTRATORS) • Utilized clinical knowledge and good clinical practice to capture RFMCF (Regular ForceMedical Continuation Fund) member information on administrative system. • Chronic disease monitoring for disease risk management using good clinical practice guidelines and generating treatment plans. • Indexed treatment plan documents for availability of authorisations. • Established regular lines of communication by Sending out RFMCF, KeyHealth and Profmed Medical Aid Scheme Correspondence to both members and providers to manage ongoing project expectations and issues. • Loaded Authorizations for clients on the Medical Aid System. • Applied medical scheme knowledge and kept effective relationship between members, providers and the medical aid schemes while developing a deepened relationship to increase loyalty and brand engagement. • Generated and resolved data query and follow up letters. • Managed the progress of disease risk management by drawing and tracking monthly departmental case report stats and sending them to the PPSHA company executives and leadership.

Educational experience

• TSHWANE university of technology

  Health Economics, Epidemiology and Biostatistics, Health care Administration and Management, Research in Life Science Methodology

  2025.01-Current

  (a year)

  PostGraduate Dploma in Pharmaceutical Sciences
• UNIVERSITY OF JOHANNESBURG

  Human Physiology, Psychology, Microbiology 2nd year level

  2013.02-2017.12

  (5 years)

  BSc Life and Environmental Sciences
• SG MAFAESA SECONDARY SCHOOL

  NATIONAL SENIOR CERTIFICATE GRADE

  2008.01-2012.12

  (5 years)

  Matric Science Stream

Languages

Certificates

Skills