Occupational Certificate: Healthcare Insurance Claims Administrator (NQF 4)

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About The Course

Healthcare Claims Assessor

Develop specialised Healthcare Claims Expertise

The Occupational Certificate: Insurance Claims Administrator (Insurance Claims Assessor) — Healthcare Claims prepares learners to verify, assess and finalise claims in a healthcare or medical benefits environment.

Learners develop the knowledge and workplace competence needed to review claims information, determine validity and support accurate payment decisions.

  • SAQA ID: 99668

  • Curriculum code: 431204001

  • NQF Level: 4

  • Credits: 131

  • Duration: Approximately 12 months

  • Entry requirement: NQF Level 4 qualification or three years of insurance experience

  • Last date for enrolment: 30 December 2026

  • Last date for achievement: 30 December 2029

You will develop the ability to:

  • Receive healthcare claim notifications

  • Verify membership and benefit information

  • Confirm relevant claimant and service-provider details

  • Review the validity and completeness of claims

  • Assess claims against available benefits and applicable rules

  • Identify exclusions, limits and other relevant conditions

  • Calculate or confirm the value of a claim

  • Support decisions on claims payments

  • Communicate claims outcomes professionally

  • Finalise healthcare claims accurately

This specialisation is ideal for:

  • Healthcare claims administrators

  • Medical scheme claims assessors

  • Medical claims processors

  • Healthcare benefit administrators

  • Claims officers and negotiators

  • Managed-care and medical scheme employees

  • Employees entering the healthcare claims environment

  • Experienced medical claims employees seeking formal recognition

Knowledge modules — 41 credits

  • Basics of insurance

  • Claims-handling procedures

  • Professional behaviour and financial literacy

Practical skills modules — 40 credits

  • Receiving a claim and verifying the contract or benefit arrangement

  • Assessing the validity of a claim

  • Recommending settlement, conditional settlement or rejection

  • Commenting on risk improvements where applicable

Healthcare work-experience modules — 50 credits

  • Receiving notifications and completing healthcare verification processes — 20 credits

  • Participating in healthcare claims assessments — 25 credits

  • Supporting payment decisions for relevant stakeholders — 5 credits

The workplace component must be completed in a suitable healthcare or medical claims environment.