Loading profile…
Zanele Jennifer Sijila
Looking for a jobBack Office Clerk / Medical Claims Assessor
Medical Claims Assessor at SAMWUMED who processed paper and EDI claims and followed up on discrepancies and outstanding cases.
South AfricaBack Office Clerk / Medical Claims Assessor at South African Municipal Workers Union Medical Scheme (SAMWUM
About
At South African Municipal Workers Union Medical Scheme (SAMWUMED), I processed and reviewed paper and Electronic Data Interchange (EDI) medical claims against scheme procedures and service-level requirements. I checked claim details and supporting documents, investigated discrepancies and followed up on missing or unclear information.
I handled claims-related enquiries, complaints and escalations, liaising with members, healthcare providers and internal departments to support resolution. I also supported authorisation workflows and worked with claims filters, special batches and outstanding cases, referring complex matters to the appropriate team.
Earlier, at Government Employees Medical Scheme (GEMS), I provided telephone and email support to members and healthcare providers. At South African Social Security Agency (SASSA), I processed applications and checked supporting documents; I also handled customer enquiries for Fusion Outsourcing's Vodacom Campaign.
Experience
Back Office Clerk / Medical Claims Assessor
Processed and reviewed paper-based and EDI medical claims, checked supporting documents, investigated discrepancies, and handled member and provider queries. Supported authorisation workflows and maintained accurate records while protecting confidential information.
Medical Claims ProcessingEDI ClaimsClaims Documentation ReviewDiscrepancy InvestigationQuery ResolutionComplaint HandlingWorkflow prioritizationMicrosoft WordExcelOutlookElectronic Records
Service Desk Agent
Provided telephone and email support to medical scheme members and providers on healthcare, account, and authorisation enquiries. Documented interactions, investigated routine issues, and escalated complex cases while maintaining confidentiality.
Education
Awona Empowerment Technologies
Completed a certificate in End User Computing.
ALX
Completed a certificate in Virtual Assistance.
SAMWUMED
Completed medical claims training.
SASSA
Completed claims processing training.
SASSA
Completed MIP and SOCPEN systems training.