Claims Team Leader

About the role

The Claims Team Leader will head the claims department, ensuring that all health‑related claims are processed accurately, comply with scheme rules and clinical protocols, and meet fraud‑prevention standards. This role balances operational excellence with cost containment while delivering high‑quality service to clients and members.

Key responsibilities

• Oversee end‑to‑end claims processing, ensuring adherence to tariffs, clinical guidelines and internal policies.
• Manage the team’s delivery against Service Level Agreements and client expectations.
• Act as escalation point for complex, high‑value or high‑risk claims and coordinate fraud investigations.
• Review and reconcile claims payable reports, monitor outstanding liabilities and support month‑end reconciliations.
• Audit medical claims for accuracy, identify process improvements and implement enhancements.
• Maintain client relationships, provide regular performance reports and advise on service improvements.

Required profile

• Tertiary qualification in a health‑related field (e.g., Nursing, MBCHB, B.Pharm, B Cur).
• Registration with the relevant regulatory body.
• 4‑6 years of claims management experience.
• 1‑2 years of people‑management experience.
• Experience in the insurance or related industry.

Required skills