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Lizelle F. — Mid-Level Claims Specialist from South Africa

Lizelle F.

Mid-Level Claims Specialist

South Africa 6+ years
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About

Lizelle F. is a seasoned professional with substantial experience in the healthcare and insurance industry as a Claims Specialist at Medscheme PTY LTD from 2001 to 2026. Her expertise lies in handling and resolving complex claim issues, including PMB, and conducting detailed audits and compliance checks. With a background as a Risk Analyst, she has excelled in collecting and analyzing data to identify critical patterns and audit findings. Key skills that define her professional scope include proficiency in the Oracle system, effective use of Microsoft 365, and adept handling of various report mechanisms. As a Query Assessor, she was responsible for resolving customer care queries, providing staff training, and managing escalations and foreign claims. Her dedication to precision and compliance has consistently contributed to the operational excellence of the organization.

Experience

  • Claims Specialist - PMB Non Clinical reviewer

    Medscheme PTY LTD · 2025 — 2026
    Reviewed PMB claims, addressed provider portal queries, and conducted interim processes for various claims, including dialysis and anaesthetic claims. Prepared claims requiring clinical review.
  • Risk Analyst

    Medscheme PTY LTD · 2011 — 2020
    Collected and analyzed data to unveil patterns, trends, insights, and actionable solutions. Conducted audits, ensured ISO compliance, and performed year-end testing for benefits, rates, and relevant formulas.
  • Query Assessor

    Medscheme PTY LTD · 2008 — 2011
    Handled the resolution of customer care queries, escalated issues via email, and managed complaints related to CMS and Hello Peter. Processed foreign claims, performed exclusion overrides, and ensured proper handling of hospital claims and year-end tax reports.
  • Intervention Clerk

    Medscheme PTY LTD · 2004 — 2008
    Reprocessed accounts, addressed nexus rejection error codes, and applied assessing rules for manual linking processes as part of daily operations. Managed various error codes and developed insights from exceptions reports.
  • Data Capturer

    Medscheme PTY LTD · 2001 — 2004
    Executed accurate capturing, validation, and processing of healthcare-related data, focusing on claims and member information within the Oracle System.

Skills & Expertise

Education

  • Grade 12
    Vereeniging High School · 1995 — 1999

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