Claims Vetter

Role Overview

This position sits at the centre of the claims function, where each decision directly affects how quickly and fairly members receive the medical cover they are entitled to. Working within the claims team, you will review incoming medical claims line by line — confirming that the member is covered, the treatment falls within the agreed benefits, and the paperwork stands up to scrutiny — before the claim moves forward for settlement. Because errors here cost both money and trust, the role carries real weight: your accuracy protects the organisation's finances, keeps the claims turnaround promise to members and providers, and keeps everything aligned with policy wording and regulatory expectations.

Key Responsibilities

• Review and vet medical claims against policy terms, conditions and internal processing rules, confirming that each claim is payable before it is approved.
• Check member eligibility and remaining benefit limits, and verify that all supporting documents — invoices, discharge summaries, prescriptions and similar records — are complete and consistent.
• Flag gaps, inconsistencies and indicators of possible fraud or abuse, escalating suspicious cases through the correct channel rather than resolving them independently.
• Capture and update claim details accurately in the claims management system, keeping records clean and traceable.
• Work within agreed turnaround times so claims are settled without avoidable delay, while maintaining accuracy under volume pressure.
• Maintain orderly documentation and audit trails for every claim handled, in line with confidentiality and data protection rules.
• Follow up with healthcare providers and colleagues in other departments to obtain missing or unclear claim information.
• Contribute to reconciliation and reporting tasks as required by the Claims & Care Manager, including periodic claims reports and any analysis assigned.

Requirements & Qualifications

• Diploma or bachelor's degree in Insurance, Health Records Management, Nursing, Business Administration, or another relevant discipline.
• Hands-on experience in claims vetting or processing, medical administration, benefits administration, or a comparable role — sufficient to read a claim and judge it confidently against policy wording.
• Working knowledge of medical claims processes and of how insurance policy terms translate into benefit entitlements.
• Strong data entry and records management skills, with the speed and precision needed for high claim volumes.
• Comfortable working in Microsoft Office applications, particularly spreadsheets and word processing.
• Solid analytical and numerical ability, including the judgement to spot discrepancies and recognise potential fraud indicators.
• Well organised and able to manage competing priorities and deadlines.
• Trustworthy and self-directed — capable of working with minimal supervision while knowing when to escalate.
• Clear communication skills for dealing with providers, members and internal teams, combined with a firm commitment to confidentiality.