External Vacancy: Back Office Agent

An exciting position has become available at our Head Office in Cape Town. Suitably qualified applicants who possess the requirements listed below are encouraged to apply. SAMWUMED is committed to transformation in Southern Africa.

Job Purpose:

Back Office Agent is responsible for investigating and resolving queries received from various sources including emails, scheme’s digital platforms such as webchat, WhatsApp and social media, delivering a professional service in a single contact in line with the scheme rules and departmental SOP’s ensuring overall member satisfaction

Key Responsibilities:

Query Management

• Adept in investigating member queries from various sources which includes, emails, webchat, WhatsApp and social media and walk-ins to ensure efficient query resolution and provide feedback timeously.

Client Service

• Responsible for being the liaison between the members and the scheme through various platforms in a professional manner.
• Manage communication via our messaging platforms with members in a professional manner
• Log communication and issue correct correspondence within SLA (80% of queries received within the required).
• Servicing all members via the scheme’s digital channels until the query has been resolved.
• Prioritise and escalate matters that cannot be resolved in a first contact.
• Address and resolve member inquiries and complaints in a professional and timely manner.
• Maintain detailed records of customer interactions and accurately update member / provider information on Nexus or relevant systems.
• Accurately input and update member information, claims, and other relevant data into the system.

Claims Processing

• Accurately assess and process out of medical aid claims including stale claims following relevant protocols.
• Liaise with healthcare providers and members to resolve discrepancies or issues related to claims
• Verify and process medical aid claims promptly and accurately, ensuring compliance with company policies and industry regulations.
• Resolve any discrepancies or issues related to claims in a timely manner
• Accurately assess and respond to claims queries considering tariff codes, Nappi codes and modifiers
• Investigate, clear rejections and ensure accurate and timely re-processing of claims

Escalations

• Escalate complex cases to higher management or relevant departments.
• Provide solutions and alternatives to ensure customer satisfaction

Quality Assurance

• Routing queries to the correct departments / external stakeholders for adequate and resolution.
• Provide continuous quality and timeous responses with members, service providers, 3^rd parties and/or the Scheme.

Compliance and Regulation

• Respond and advise member queries in accordance with Medical Aid Scheme Act legislation.
• Maintain ISO9001:2015 standards and adherence to the POPI Act and other relevant regulatory bodies.
• Assist in fraud control, risk prevention, and compliance processes.
• Ensure adherence to clinical and/or non-clinical guidelines and processes.

Minimum Requirements:

Qualifications

• Senior Certificate or relevant NQF level 4 qualification

Experience

• 2-3 years’ experience in medical aid industry.
• Comprehensive knowledge of assessing claims, ICD10 /tariff codes, Nappi codes and modifiers.
• Understanding claims assessing rules and operational systems are essential.
• Clinical risk assessment experience within the medical industry.
• Vast experience with the interpretation, understanding and applications of Scheme Rules including Medical Aid Scheme’s Act
• Experience in training teams on new technologies and facilitating change management.

Capabilities:

• Communication Skills: Ability to communicate at all levels, both internally and externally
• Training and Development: Participate in ongoing training and development to stay updated on industry trends, regulations and best practices
• Monitoring and Evaluation: Keeping abreast of all processes/benefit changes or updates. Continuously staying abreast of all digital servicing tools within the Scheme and ensuring that the functionality is fully understood. Stay informed about changes in regulations and best practices related to medical aid administration.
• Time Management: Compliance with the department’s adherence to schedule
• Team Collaboration: Work collaboratively with other team members to ensure efficient operations and high-quality service delivery

Persons interested in applying for the above position are requested to forward a comprehensive CV to recruitment@samwumed.org. Persons with disabilities are encouraged to apply.

The Closing date for applications is Thursday, 25 September 2025

The Scheme reserves the right not to make an appointment. Should you not hear from us within two weeks of the closing date, please regard your application as unsuccessful.

Disclaimer: 

Your personal data submitted will be dealt with on a strictly confidential and discreet basis and processed in relation to this job application and will be stored and processed securely in accordance with our data information policy and procedures. By submitting an application, you agree to your data being used, stored and processed for the purpose of recruitment.