TSHEPO GREGORY KGOADI
Claims Risk Analyst
ROODEPOORT
Summary
Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Dynamic individual with hands-on experience in Medical aid administrtion and talent for navigating challenges. Brings strong problem-solving skills and proactive approach to new tasks. Known for adaptability, creativity, and results-oriented mindset. Committed to making meaningful contributions and advancing organizational goals.
Overview
2025
2025
years of professional experience
1998
1998
years of post-secondary education
4
4
Languages
Work History
Pathology Claims Analyst
Medscheme
Johannesburg
06.2018 - 09.2024
- Multi skilled in Assessing, and Pathology back office claims
- Maintaining service level agreement for call schemes administered by Medscheme
- Responsible for FTQR (first time query resolution)
- Resolving member/health care professional queries within a specific turnaround time
- Routing and preparation of advisory cases such as medical aid cases and ex-gratia claims
- Drafting correspondence
- Reconciling unpaid claims and providing ongoing feedback to customers & providers of service
- Processing of pathology claims
- Requesting and analyzing of data extracts for pathology claims
- Daily stats for department
- Conduct ad-hoc jobs when team leader is unavailable
- Maintaining good relationships with providers
- Interpretation of scheme annexures and ensuring claims are linked to the correct plan benefit and pay according to scheme rules
- Assisting with CMS and escalated queries
- Assisting with PMB queries
- Informed clients of policies and procedures.
- De-escalated and resolved customer complaints with punctual, polite and professional service.
- Delivered exceptional customer service by proactively addressing concerns and fostering a positive experience throughout all interactions.
- Assisted clients in navigating the claims process, ensuring timely resolution of issues and optimal outcomes.
- Enhanced client satisfaction by promptly addressing inquiries and providing accurate information on products and services.
- Spearheaded team training initiatives, equipping agents with essential skills to excel in their roles.
Health Coach
Polmed
4 2017 - Current
- Company Overview: ADRM Department
- Call members who are identified with chronic conditions and register them on our health support programme
- Aim for the programme is to give support and information to better manage chronic conditions
- Register members with the information received from wellness programmes that are conducted at police stations
- Follow ups are done every 3 to 6 months
- Assist in referring members who need emotional and mental support to our social workers and counselors
- ADRM Department
Prospective Reviewer
Medscheme
01.2014 - 03.2017
- Assisting with loading clinical cases, loading authorization for hospitals
- Loading radiology scans, chemo drugs and radiation auths
- Taking calls from members, pharmacies and doctors in connection with oncology related queries
- Check oncology benefits and educate member and all stakeholders of Medscheme about oncology
- Assist with claims related requests
- Appointed as a group leader for the call center
- Assisting with weekly calls assessment for the team for training sessions using (NICE SYSTEM)
- Maintained strict confidentiality with sensitive client information, adhering to industry standards and company policies.
- Reduced turnaround time for reviews by effectively prioritizing tasks and managing deadlines.
Education
GRADE 12 - ENGLISH 1ST LANGUAGE, AFRIKAANS 2ND LANGUAGE, BIOLOGY, HISTORY, MATHEMATICS, PHYSICAL SCIENCE
BELFAST ACADEMY
ELECTRICAL ENGINEERING - COMMUNICATION, ELECTRONICS N4, DIGITAL ELECTRONICS N4, MATHEMATICS N4
ATTERIDGEVILLE TECHNICAL COLLEGE
ELECTRICAL ENGINEERING - COMMUNICATION SKILLS 1, ELECTRICAL ENGINEERING 1, ELECTRONICS 1, PROCESS INSTUMENTATION 1, COMPUTER SKILLS 1
VAAL UNIVERSITY OF TECHNOLOGY
CERTIFICATE IN PC ENGINEERING - BUSINESS PRACTICE, COMPUTER ARCHITECTURE ( A+), COMPUTER LITERACY, DATABASE ADVANCED, DATABASE INTRODUCTION, ELECTRONIC MAIL, HELP DESK, WORK DEVELOPMENT INTRODUCTION, NETWORK ARCHITECTURE (N+), PRESENTATION GRAPHICS, MICROSOFT EXEL, MICROSOFT WORD, BUSINESS COMMUNICATION, INTRODUCTION TO PROGRAMMING (VB.NET)
COLLEGE CAMPUS
DIPLOMA IN NETWORKING - undefined
COLLEGE CAMPUS
Skills
Health Education
Public speaking abilities
Coaching
Collaborative Teamwork
Stress Management Strategies
Educating healthcare clients
Client Motivation Methods
Problem-Solving
Teamwork and Collaboration
Multitasking Abilities
Adaptability
Analytical Thinking
Highschoolqualifications
BELFAST ACADEMY, GRADE 12, 1998, ENGLISH 1ST LANGUAGE, AFRIKAANS 2ND LANGUAGE, BIOLOGY, HISTORY, MATHEMATICS, PHYSICAL SCIENCE
Personal Information
- ID Number: 8012195428088
- Gender: MALE
- Nationality: SOUTH AFRICAN
Reference
Mrs Mumtaz Mahomed 083 3752031
Timeline
Pathology Claims Analyst
Medscheme
06.2018 - 09.2024
Prospective Reviewer
Medscheme
01.2014 - 03.2017
ELECTRICAL ENGINEERING - COMMUNICATION, ELECTRONICS N4, DIGITAL ELECTRONICS N4, MATHEMATICS N4
ATTERIDGEVILLE TECHNICAL COLLEGE
ELECTRICAL ENGINEERING - COMMUNICATION SKILLS 1, ELECTRICAL ENGINEERING 1, ELECTRONICS 1, PROCESS INSTUMENTATION 1, COMPUTER SKILLS 1
VAAL UNIVERSITY OF TECHNOLOGY
CERTIFICATE IN PC ENGINEERING - BUSINESS PRACTICE, COMPUTER ARCHITECTURE ( A+), COMPUTER LITERACY, DATABASE ADVANCED, DATABASE INTRODUCTION, ELECTRONIC MAIL, HELP DESK, WORK DEVELOPMENT INTRODUCTION, NETWORK ARCHITECTURE (N+), PRESENTATION GRAPHICS, MICROSOFT EXEL, MICROSOFT WORD, BUSINESS COMMUNICATION, INTRODUCTION TO PROGRAMMING (VB.NET)
COLLEGE CAMPUS
DIPLOMA IN NETWORKING - undefined
COLLEGE CAMPUS
Health Coach
Polmed
4 2017 - Current
GRADE 12 - ENGLISH 1ST LANGUAGE, AFRIKAANS 2ND LANGUAGE, BIOLOGY, HISTORY, MATHEMATICS, PHYSICAL SCIENCE
BELFAST ACADEMY
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