A vacancy exists for a Team Lead – Claim Submission Specialist, based at our Cape Town Regional office reporting to the National Case Manager.

The successful candidate will be responsible for leading and managing a team of Claim Submission Specialists to ensure optimal claims submission, revenue realisation, and quality performance. The role focuses on driving operational excellence, compliance, efficiency, and stakeholder satisfaction within the claim’s submission function.

Critical Outputs
Ensuring the appropriate optimisation of revenue:

Ensure accurate and complete claim submission and optimal funder contract interpretation
Monitor billing accuracy, coding quality, and claim completeness
Oversee management of rejections, short payments, and escalations
Analyse revenue cycle reports (e.g. DNFB, DSO, coding audits) and implement improvements
Identify revenue risks, gaps, and opportunities and implement corrective actions
Drive improvement in clean claim rates and reduce revenue leakage
Ensuring operational excellence:

Lead and manage day-to-day operations of the claim submission team
Monitor workflow management, including real-time messaging, submissions, and rejections
Ensure adherence to patient services policies, procedures, and SLAs
Manage workload distribution, productivity, and turnaround times
Identify operational inefficiencies and drive continuous improvement initiatives
Ensure compliance with governance, risk, and audit requirements
Manage End-to-End Claim Processing
Manage claims from Bill Ready to Final Billed status
Manage initial claims and amended claims where required
Continuously monitor claims that fail or reject and rework them until resolved
Work across multiple system statuses (e.g. rejected, failed, integration errors)
Ensuring effective management of quality and compliance:

Ensure adherence to QMS, ISO standards, and internal audit requirements
Monitor audit outcomes, coding accuracy, and compliance metrics
Drive a culture of quality, accuracy, and continuous improvement
Ensure adherence to escalation processes and quality standards
Manage line-by-line validation of accounts prior to submission
Manage Quality Assurance of team on checking Length of stay (LOS), Level of care (LOC), Billing methods and modifiers, System and configuration accuracy
Manage identification of errors or missing information and ensure process followed to refer cases to the allocated Case Manager for correction
Manage System Monitoring & Exception Handling

Monitor dashboards and reports (e.g. DNFB, Finalise a Bill)
Manage the Follow up of Claims >24 hours in a status, Failed integrations, Outstanding billing processes
Ensure no claim remains unresolved in the workflow
Reporting and Trend Identification

Track patterns in rejections and failures
Provide feedback on common errors, System issues and Process gaps
Ensuring effective people leadership:

Lead, coach, and develop Claim Submission Specialists
Set performance expectations and manage team KPIs
Conduct performance reviews and address underperformance
Drive team engagement, accountability, and motivation
Support change management and adoption of new processes and systems
Ensure ongoing training and upskilling of team members
Ensuring effective stakeholder management:

Build and maintain strong relationships with internal stakeholders (case management, nursing, finance, pharmacy)
Engage effectively with external stakeholders (funders and doctors)
Manage and escalate stakeholder issues impacting claim submission
Provide feedback on systemic challenges affecting efficiency and revenue
Facilitate communication and training on funder requirements and processes

Requirements

Nursing Qualification, preferably Professional Nurse with at least 5 years’ experience
Proven case manager and clinical coding experience of at least 5 years.
Proven experience in leadership, change management, and people management
Current registration with the relevant professional/regulatory body (South African Nursing Council)
Knowledge of hospital patient services and case management processes
Knowledge of CPT & ICD coding and clinical terminology
Understanding of funder rules, contracts, co-payments, exclusions, and benefits
Knowledge of hospital billing systems and processes
Computer proficiency

Competencies

Attention to detail
Problem-solving, analysis and judgement
Resilience
Engaging diversity
Verbal & written communication skills
Professional and technical proficiency
Building relationships
Customer responsiveness
Organisational awareness
Influencing skills
Action orientation
Excellence orientation
Ethical behaviour
Drive and energy

Please send your resume/CV