Position: Junior Claims Administrator – Cinagi Gap Cover

1. Role Purpose

The Junior Claims Administrator is responsible for capturing, validating and processing Cinagi Gap Cover claims in a timely, accurate and customer-centric manner.

The role supports the end-to-end claims process – from first notification of loss to final outcome – ensuring that all claims are handled in line with Cinagi’s policies, service standards and relevant regulatory and insurer requirements.

2. Key Responsibilities

2.1 Claims Intake & Registration

• Receive and log new claims via email, telephone, portals or integrated systems.
• Check that all required documentation has been submitted (claims forms, hospital accounts, medical scheme statements, clinical notes, etc.).
• Capture claim details accurately on the Cinagi claims system.

2.2 Validation & Assessment Support

• Perform initial validation checks (membership status, policy status, waiting periods, benefit eligibility, limits, etc.).
• Compare medical scheme payments vs. provider accounts to identify shortfalls in line with Gap Cover benefits.
• Flag incomplete or unclear documentation and request outstanding information from members, brokers or providers.
• Prepare claim files for review by the Senior Claims Administrator / Claims Assessor where required.

2.3 Member, Broker & Provider Communication

• Communicate clearly and professionally with members, brokers and providers regarding:
  • Required documents
  • Claim status updates
  • Outcome explanations (approved/partially paid/declined)
• Respond to inbound queries within agreed service levels.
• Escalate complex or sensitive complaints to the Claims Manager timeously.

2.4 Processing & Administration

• Capture claim decisions and payment details on the system once authorised.
• Ensure all electronic records, notes and documents are complete, neat and correctly filed.
• Assist with preparing payment batches and reconciliations where required.
• Support monthly reporting and internal audit requests by providing accurate claim data.

2.5 Compliance, Quality & Controls

• Work in accordance with Cinagi’s internal processes, SLAs and quality standards.
• Adhere to relevant legislation and regulations (including POPIA, TCF principles and insurer guidelines).
• Maintain confidentiality of member and claims information at all times.

2.6 Continuous Improvement

• Identify recurring issues (e.g. missing documentation, common errors) and suggest process improvements.
• Participate in training sessions, product updates and system enhancements.

3. Minimum Requirements

Education & Qualifications

• Grade 12 / Matric (essential).
• A relevant short course or certificate in insurance will be advantageous.
• RE 5 (essential).

Experience

• Minimum 1–2 years’ experience in a claims or healthcare administration environment, preferably in one or more of the following:
  • Gap Cover / top-up medical insurance
  • Medical scheme / medical aid claims
  • Health / life insurance claims
• Experience working with claim documents, hospital accounts and medical scheme remittance advices is strongly preferred.

Technical & System Skills

• Comfortable working on insurance/claims administration systems.
• Proficient in MS Office (especially Outlook, Excel and Word).
• Ability to learn new systems and digital tools quickly.

4. Knowledge & Competencies

Industry & Product Knowledge (advantageous, can be developed on the job)

• Basic understanding of:
  • Medical schemes, gap cover and provider billing.
  • Shortfalls, co-payments and tariff differences.
  • Waiting periods, pre-existing conditions and standard exclusions.
• Exposure to ICD-10 codes and medical tariff codes will be an advantage.

Core Competencies

• Strong attention to detail and high degree of accuracy.
• Good numerical and analytical ability (reconciling statements, identifying shortfalls).
• Clear written and verbal communication skills (English; additional SA languages beneficial).
• Strong organisational skills with the ability to manage multiple claims simultaneously.
• Customer-centric mindset with a calm, professional approach to member queries.
• Ability to work in a small, fast-moving team and handle changing priorities.