Mamolewa MODIBA
Clinical Claims Adjudication Manager
Summary
I am a collaborative leader who partners with coworkers to promote engaged, empowering work culture. My documented strengths are in building and maintaining relationships with diverse range of stakeholders in dynamic, fast-paced settings.
I am a seasoned operational leader with over 15 years of experience in the life insurance and compensation industries. My expertise includes managing large multidisciplinary teams, driving operational efficiency, and delivering business growth through strategic planning and process optimization. I have a proven track record of managing complex projects, ensuring regulatory compliance, and enhancing customer satisfaction. I bring a results-driven approach and a strong ability to align operational practices with organizational goals.
Overview
24
24
years of professional experience
Work History
Clinical Claims Adjudication Manager
Rand Mutual Assurance
05.2020 - Current
- Lead and inspire clinical claims specialists team, setting performance targets and achieving a consistent 20% annual growth in the division.
- Prepare high-quality executive reports on performance metrics, operational insights, and risk assessments.
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Accomplished multiple tasks within established timeframes.
- Maximized performance by monitoring daily activities and mentoring team members.
- Managed end-to-end claims processes, ensuring adherence to regulations and protocols.
- Drive operational improvements, including system enhancements, fraud detection, and payment accuracy.
- Develop risk mitigation strategies, reducing operational losses and protecting reputation.
- Managed and motivate employees to be productive and engaged in work.
Claims Manager
Professional Provident Society (PPS)
12.2017 - 04.2020
- Documented and communicated timely claims business processes while supporting accurate outcomes.
- Handled claims consistent with client and corporate policies, procedures, best practices and regulations.
- Managed communication strategies to enhance client experience and streamline claim adjudication processes.
- Gathered sensitive information to update customer profiles and help with appeals process.
- Oversaw full claims management and complaints resolution functions.
- Enhanced member claims experience, increasing satisfaction rates from 80% to 95%.
- Developed the TELECLAIMS platform, reducing claims processing time from seven days to same-day resolution.
Credit Life Claims Manager
Standard Bank Insurance Brokers (SBIB)
12.2014 - 11.2017
- Championed insurance claims process by providing expert knowledge and building positive, trusting relationship to support clients during challenging times.
- Managed risk claims ensuring compliance with product terms and minimizing financial loss.
- Provided technical training to staff, improving claims accuracy and operational efficiency.
- Documented and communicated timely claims information while supporting accurate outcomes.
- Handled claims consistent with client and corporate policies, procedures, best practices and regulations.
- Determined proper course of action for claims processing.
- Collaborated across departments to implement synergistic workflows and mitigate risks.
Disability Manager
South African Social Security Agency (SASSA)
02.2008 - 11.2014
- Increased staff retention through fostering a positive work environment and addressing employee concerns promptly.
- Promoted inclusive environments by facilitating disability awareness workshops for employees across various departments in the organization.
- Developed strong relationships with community partners to enhance available resources for clients within the disability program.
- Continuously updated knowledge on industry trends in order to provide the most effective and current support to clients.
- Directed strategic planning and budgeting for disability-related grants administration.
- Improved operational strategies to streamline processes and enhance service delivery.
- Built and maintained stakeholder relationships to ensure transparent decision-making.
Claims Assessor
Compensation Fund
01.2006 - 01.2008
- Participated in regular meetings with other departments to provide insights on emerging trends in claims activity, influencing strategic decision-making processes within the organization.
- Ensured compliance with regulatory guidelines by staying up-to-date on industry standards and integrating them into daily workflows.
- Enhanced customer satisfaction rates by promptly addressing inquiries and providing detailed explanations regarding claim decisions.
- Identified fraudulent claims with comprehensive investigations, minimizing company losses and maintaining integrity in the claims process.
- Evaluated occupational therapy-related claims, ensuring compliance with legislation.
- Trained staff on medical injuries and efficient claims management.
Occupational Therapist
Limpopo Department of Health
01.2001 - 12.2005
- Enhanced patient functionality through evidence-based therapeutic interventions and exercises.
- Provided education to patients and families on coping strategies, adaptive equipment, and safety modifications.
- Collaborated with interdisciplinary team members for comprehensive patient care and optimal results.
- Customized standard plans to meet individual abilities and needs.
- Provided therapeutic services and supervised assistants, contributing to patient rehabilitation and community awareness campaigns.
Education
Advanced Diploma in Management - Management
Henley Business School
Johannesburg, South Africa 04.2001 -
LLB - Law
UNISA
Pretoria 04.2001 -
Master of Science - Corporate Strategy
Masters in Business Leadership
UNISA: SBL 04.2001 -
Bachelor of Science - Health Sciences
Sefako Makgatho Health Sciences University
Gauteng 04.2001 -
Skills
Operational Workflow Optimization
Claims Management and Adjudication
Strategic Planning and Business Growth
Regulatory Compliance and Risk Mitigation
Leadership and Team Development
Customer Service Excellence
Financial Acumen and Budget Management
IT Systems and Software Proficiency
Accomplishments
- Designed and implemented a disability management service model for SASSA, improving service delivery.
- Established TELECLAIMS at PPS, revolutionizing claims processing cycles.
- Developed risk mitigation strategies at Rand Mutual Assurance, reducing operational losses.
Timeline
Clinical Claims Adjudication Manager
Rand Mutual Assurance
05.2020 - Current
Claims Manager
Professional Provident Society (PPS)
12.2017 - 04.2020
Credit Life Claims Manager
Standard Bank Insurance Brokers (SBIB)
12.2014 - 11.2017
Disability Manager
South African Social Security Agency (SASSA)
02.2008 - 11.2014
Claims Assessor
Compensation Fund
01.2006 - 01.2008
Advanced Diploma in Management - Management
Henley Business School
04.2001 -
LLB - Law
UNISA
04.2001 -
Master of Science - Corporate Strategy
Masters in Business Leadership
04.2001 -
Bachelor of Science - Health Sciences
Sefako Makgatho Health Sciences University
04.2001 -
Occupational Therapist
Limpopo Department of Health
01.2001 - 12.2005
Similar Profiles
SYLVIA KEDIBONE SEDIBESYLVIA KEDIBONE SEDIBE
Life Claims Assessor at Rand Mutual AssuranceLife Claims Assessor at Rand Mutual Assurance
Njabulo MoloiNjabulo Moloi
Junior Financial Advisor (JFA) at Rand Mutual AssuranceJunior Financial Advisor (JFA) at Rand Mutual Assurance
Neo KhunouNeo Khunou
Test Manager (Testing Centre of Excellence) at Rand Mutual AssuranceTest Manager (Testing Centre of Excellence) at Rand Mutual Assurance
Christian ThompsonChristian Thompson
Claims Adjudication Manager at TrupanionClaims Adjudication Manager at Trupanion
Deborah LeiningerDeborah Leininger
Sr. Engineering Manager/Interim Director, IT Claims Pre-Adjudication and Encounters at Elevance HealthSr. Engineering Manager/Interim Director, IT Claims Pre-Adjudication and Encounters at Elevance Health