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Zanele Jennifer Sijila

@zanelejennifersijila

Medical Claims Assessor at SAMWUMED who processed paper and EDI claims and followed up on discrepancies and outstanding cases.

South Africa

Message

What I'm looking for

I'm looking for senior claims administration or claims operations work where I can apply my experience with accurate claims processing, fair procedures, reliable service and complex case escalation.

At South African Municipal Workers Union Medical Scheme (SAMWUMED), I processed and reviewed paper and Electronic Data Interchange (EDI) medical claims against scheme procedures and service-level requirements. I checked claim details and supporting documents, investigated discrepancies and followed up on missing or unclear information.

I handled claims-related enquiries, complaints and escalations, liaising with members, healthcare providers and internal departments to support resolution. I also supported authorisation workflows and worked with claims filters, special batches and outstanding cases, referring complex matters to the appropriate team.

Earlier, at Government Employees Medical Scheme (GEMS), I provided telephone and email support to members and healthcare providers. At South African Social Security Agency (SASSA), I processed applications and checked supporting documents; I also handled customer enquiries for Fusion Outsourcing's Vodacom Campaign.

Experience

Work history, roles, and key accomplishments

Back Office Clerk / Medical Claims Assessor

South African Municipal Workers Union Medical Scheme (SAMWUM

Jan 2016 - Dec 2024 (8 years 11 months)

Processed and reviewed paper-based and EDI medical claims, checked supporting documents, investigated discrepancies, and handled member and provider queries. Supported authorisation workflows and maintained accurate records while protecting confidential information.

Medical Claims Processing EDI Claims Claims Documentation Review Discrepancy Investigation Query Resolution Complaint Handling Workflow prioritization Microsoft Word Excel Outlook Electronic Records

Service Desk Agent

Government Employees Medical Scheme (GEMS)

Jan 2015 - Dec 2016 (1 year 11 months)

Provided telephone and email support to medical scheme members and providers on healthcare, account, and authorisation enquiries. Documented interactions, investigated routine issues, and escalated complex cases while maintaining confidentiality.

Customer Service Active Listening Communication Skills Data Capture Case Management Escalation Management Confidentiality

Grant Administrator

South African Social Security Agency (SASSA)

Jan 2013 - Dec 2014 (1 year 11 months)

Processed applications and checked supporting documents against requirements. Captured client information accurately, maintained records, and followed up on missing information to support timely processing.

Claims Processing Data Capture Record keeping Customer Service Follow up Confidentiality

Customer Service Agent

Fusion Outsourcing (Vodacom Campaign)

Jan 2011 - Dec 2012 (1 year 11 months)

Handled customer enquiries in a contact-centre environment, using active listening and clear communication. Updated records, resolved routine issues, and referred complex matters to relevant teams.

Customer Service Active Listening Communication Skills Data Entry Issue Resolution Escalation Management