Claims Team Leader – Manage Claims Operations

About the role

The Claims Team Leader is responsible for directing a claims team to ensure accurate, compliant, and cost‑effective processing of medical claims. The role balances operational excellence, client service, and people leadership while supporting fraud prevention and continuous improvement.

Key responsibilities

• Oversee claims processing to ensure compliance with scheme rules, tariffs, clinical guidelines and policies.
• Manage team delivery against Service Level Agreements and monitor client queries and turnaround times.
• Act as escalation point for complex, high‑value or high‑risk claims and coordinate fraud investigations.
• Review and reconcile claims payable reports, support month‑end reconciliation and monitor outstanding liabilities.
• Analyse claims administration processes, identify improvement opportunities and implement enhancements.
• Provide expert advice to clients, negotiate service agreements and deliver regular performance reports.
• Foster a positive work climate, lead recruitment, performance management and employee development.

Required profile

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

Required skills

• Claims processing and audit.
• Compliance with clinical guidelines and tariff structures.
• Fraud detection and escalation.
• Service Level Agreement (SLA) management.

What we offer

• Opportunity to lead a high‑performing claims team.
• Exposure to complex medical claims and strategic client relationships.
• Professional development in healthcare insurance and leadership.