PMB Specialist – Medical Claims

About the role

Join a growing healthcare technology and medical claims business that values learning, accountability, openness and collaboration. The PMB Specialist will own the review and processing of Prescribed Minimum Benefit (PMB) claims, ensuring compliance with scheme requirements and timely resolution of issues.

Key responsibilities

• Take ownership of PMB claims identified for specialist review.
• Complete and submit PMB applications together with scheme‑specific supporting documents.
• Assess claims against PMB requirements and return non‑qualifying cases to the administrator.
• Collaborate with surgeons and healthcare providers to obtain clinical notes, ICD‑10 codes and supporting information.
• Track scheme turnaround times and follow up promptly when review periods expire.
• Investigate payment differences and challenge incorrect PMB rejections or funding decisions.
• Escalate unresolved matters through appropriate medical scheme channels, including Principal Officers.
• Prepare and manage formal complaints to the Council for Medical Schemes when obligations are not met.

Required profile

• 2–3 years of experience in healthcare or medical claims.
• Strong knowledge of the PMB process and ability to assess scheme compliance.
• Matric qualification; an administrative qualification is advantageous.
• Excellent analytical, problem‑solving and attention‑to‑detail abilities.
• Clear communication skills and a client‑focused, resilient mindset.