Summary
Overview
Work History
Education
Skills
Additional Information
Timeline
Generic
Matebalo  Aphane

Matebalo Aphane

Claims Specialist
Vosloorus

Summary

Experienced Claims Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 10 years of experience and willingness to take on any challenge. Tactful Claims Specialist with expertise in settlement preparation, claims processing and appeal filing. Diplomatic and personable professional accustomed to handling sensitive, confidential information and investigating complex liability claims. Committed to maintaining customer satisfaction and contributing to company success. Enthusiastic claims specialist & clams assessor examines claims, negotiates and processes settlements and verifies insurance coverage. Attentive team player consistently treats clients fairly and equitably. Motivated to succeed in fast-paced and deadline-driven professional environment. Friendly insurance professional experienced in investigating and processing insurance claims. Hardworking and communicative individual excels at interpreting policies and negotiating payment solutions. Recognized for providing optimum service to policyholders and quickly identifying fraudulent claims. Gifted in working with stressed, confused and upset individuals in need of benefits information and supportive guidance to navigate systems. Effective at operating within the fais regulations and department guidelines to manage telephone calls, emails, letters and in-person requests for assistance. Highly trained professional with a background in verifying insurance benefits and creating appropriate patient documentation. An established Insurance Verification Specialist known for handling various office tasks with undeniable ease. Pragmatic Insurance Verification Specialist touting 9 years of expertise in benefits explanation and coverage tracking. A team player with a vast knowledge of medical terms and working with all types of personalities effectively. Offering dynamic organizational skills and attention to detail. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Hardworking and passionate job seeker with strong organizational skills. Ready to help team achieve company goals.

Overview

12
12
years of professional experience

Work History

Claims Specialist

OUTSURANCE
07.2021 - Current
  • Conducted full claim investigations and reported updates and legal actions.
  • Escalated files with significant indemnity exposure to supervisor for further investigation.
  • Utilized appropriate cost containment techniques to reduce overall claim costs.
  • Reviewed new files to determine current status of injury claim and to develop plan of action.
  • Followed up with customers on unresolved issues.
  • Negotiated with other involved parties to arrange settlements for maximum results.
  • Reviewed insurance and claims documents to verify required information and secure any missing data for settlements.
  • Drafted and reviewed legal documents utilizing knowledge of relevant clauses to minimize incurred liability.
  • Collaborated with legal counsel to make organizational claims decisions aligning with governing laws.
  • Conducted risk evaluations on claims settlement proposals to encourage sound decision-making regarding settlement offers.
  • Provided advice to customers regarding claims, rights and insurance processes to prevent disputes.
  • Responded to inquiries by answering questions, providing information and directing customers to appropriate resources.
  • Understood requirements for disputes, gathered evidence to support claims and prepared customer cases to handle appeals.
  • Monitored compliance with regulations and industry best practices to promote fair and proper treatment for insured customers.
  • Performed administrative duties by verifying documentation, researching facts and contacting other parties involved to determine fault percentages and minimize potential losses.
  • Collected premiums and issued accurate receipts.
  • Calculated adjustments, premiums and refunds.
  • Communicated effectively with staff members of operations, finance and clinical departments.
  • Generated, posted and attached information to claim files.
  • Coordinated with contracting department to resolve payer issues.
  • Maintained strong knowledge of basic medical terminology to better understand services and procedures.
  • Communicated verification and authorization status updates with department to facilitate decision-making for patient admissions and insurance coverage.
  • Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
  • Made contact with insurance carriers to discuss policies and individual patient benefits.
  • Processed and recorded new policies and claims.
  • Carried out administrative tasks by communicating with clients, distributing mail, and scanning documents.
  • Determined appropriateness of payers to protect organization and minimize risk.
  • Notified insurance agents and accounting departments of policy cancellations and changes.
  • Posted payments to accounts and maintained records.
  • Reviewed outstanding requests and redirected workloads to complete projects on time.

Non Motor Desktop Asessor (pilot Program 3months )

OUTSURANCE
Centurion
04.2022 - 07.2023
  • Acted as a team leader in group projects, delegating tasks and providing feedback.
  • Worked effectively in fast-paced environments.
  • Self-motivated, with a strong sense of personal responsibility.
  • Applied effective time management techniques to meet tight deadlines.
  • Identified issues, analyzed information and provided solutions to problems.
  • Proved successful working within tight deadlines and a fast-paced environment.
  • Participated in team projects, demonstrating an ability to work collaboratively and effectively.
  • Demonstrated strong organizational and time management skills while managing multiple projects.

Claims Administration Acting Team Manager

OUTSURANCE
Johannesburg
11.2022 - 01.2023
  • Managed time efficiently in order to complete all tasks within deadlines.
  • Demonstrated creativity and resourcefulness through the development of innovative solutions.
  • Proved successful working within tight deadlines and a fast-paced environment.
  • Cultivated interpersonal skills by building positive relationships with others.
  • Participated in team projects, demonstrating an ability to work collaboratively and effectively.
  • Demonstrated leadership skills in managing projects from concept to completion.
  • Exercised leadership capabilities by successfully motivating and inspiring others.
  • Demonstrated respect, friendliness and willingness to help wherever needed.
  • Learned and adapted quickly to new technology and software applications.
  • Worked effectively in fast-paced environments.
  • Demonstrated a high level of initiative and creativity while tackling difficult tasks.
  • Skilled at working independently and collaboratively in a team environment.
  • Ran errands and provided general office support in a professional environment.
  • Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
  • Self-motivated, with a strong sense of personal responsibility.
  • Proven ability to learn quickly and adapt to new situations.

PositionNon Motor Broker consultant

Discovery
08.2020 - 06.2021
  • Participated in team projects, demonstrating an ability to work collaboratively and effectively.
  • Resolved problems, improved operations and provided exceptional service.
  • Proven ability to learn quickly and adapt to new situations.
  • Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
  • Delivered services to customer locations within specific timeframes.
  • Adaptable and proficient in learning new concepts quickly and efficiently.
  • Applied effective time management techniques to meet tight deadlines.
  • Proved successful working within tight deadlines and a fast-paced environment.
  • Proven ability to develop and implement creative solutions to complex problems.
  • Gained extensive knowledge in data entry, analysis and reporting.

PositionRecoveries Insured Advisor

Discovery Insure
08.2019 - 07.2020

PositionFinancial Advisor

OLD MUTUAL
03.2019 - 07.2019
  • Advise clients on long term policies & sales.

PositionClaims Advisor

11.2014 - 04.2018
  • DutiesCapture Non Motor Claims For Buildings And Contents And Personal Specified And Unspecified Contents
  • Underwriting, Request Replacement Quotes From Service Providers, Appoint Service Providers For Repairs On Claims
  • Authorise And Finalise Claims
  • Process Payments to Clients and Service Providers
  • Deal with Claim Related Queries
  • Process payments and invoices for service providers and balancing payments made on excel list
  • Following up on outstanding invoices .ensure that invoices are VAT compliant .Follow up on invoices from service providers
  • Balancing payments spread sheets.

PositionOffice Manager /Administrator

01.2012 - 06.2014
  • Duties Maintain Office Records, Design Filing Systems, Ensure Protection And Security Of Files And Records
  • Daily and monthly filing of payments , following up on outstanding invoices and sorting out creditors queries , processing payments for contractors and site workers
  • Maintain and Replenish Inventory, Capturing
  • Financial Records, Operating the Switch Board, Assist the Executive Director and Other Staff As Requested, Invoicing, Payments and Data Capturing, Compiling Tender Documents
  • Ensuring that invoices are VAT complaint
  • CompanyOutsurance

PositionAssistant Manager

CompanyOnke Consulting (Pty) Ltd
12.2010 - 12.2010

PositionSales Assistant

Forever New
06.2010 - 11.2010

PositionAdministrator and Receptionist

CompanyJoint Prosperity
01.2008 - 06.2008
  • The 16th to July The 18th)
  • Period 1

Education

Work InstitutionBusby Retail House Certificate ObtainedPoint Of Service Training (Passed With Distinction) -

High SchoolDinwiddie High School

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InstitutionCTI (Computer Training Institute)

QualificationFais Credits28 Credits - undefined

Bedfordview Campus

Diploma - undefined

InstitutionUniversity Of Johannesburg

Skills

Team Building Skillsundefined

Additional Information



Company Busby Retail (Forever New)

AnttoinetteBaloyi 0116171969 /0737319365/ 011 435 5980


Company Onke Consulting (Pty) Ltd

AbongileSakwe 078 469 6354/011 432 0762

SiyabongaMpinda 083 463 6213


Company Outsurance

Team Managers Koketso Dithung 012 673 3052/0813950068


Company OLD MUTUAL

Manager Themba Manana 0118679700/0713530872


Company Telesure

Manager Hlengiwe Radebe 011 489 4216/0721847751


Company Discovery Insure

Manager Kagiso Shabangu 011 529 5911 /0815280514


Recent References

Company Outsurance

Manager Wendel Tucker 012 6887335/ 0745622926

Company Outsurance

Building Assessing Manager Siza Mabanga 012 749 5055/ 0660218819



Manager Kagiso Shabangu 011 529 5911 /0815280514

Company Outsurance

Timeline

Claims Administration Acting Team Manager

OUTSURANCE
11.2022 - 01.2023

Non Motor Desktop Asessor (pilot Program 3months )

OUTSURANCE
04.2022 - 07.2023

Claims Specialist

OUTSURANCE
07.2021 - Current

PositionNon Motor Broker consultant

Discovery
08.2020 - 06.2021

PositionRecoveries Insured Advisor

Discovery Insure
08.2019 - 07.2020

PositionFinancial Advisor

OLD MUTUAL
03.2019 - 07.2019

PositionClaims Advisor

11.2014 - 04.2018

PositionOffice Manager /Administrator

01.2012 - 06.2014

PositionAssistant Manager

CompanyOnke Consulting (Pty) Ltd
12.2010 - 12.2010

PositionSales Assistant

Forever New
06.2010 - 11.2010

PositionAdministrator and Receptionist

CompanyJoint Prosperity
01.2008 - 06.2008

Work InstitutionBusby Retail House Certificate ObtainedPoint Of Service Training (Passed With Distinction) -

High SchoolDinwiddie High School

undefined

InstitutionCTI (Computer Training Institute)

QualificationFais Credits28 Credits - undefined

Bedfordview Campus

Diploma - undefined

InstitutionUniversity Of Johannesburg
Matebalo AphaneClaims Specialist