Clinical Claims Adjudicator at Rand Mutual - RMA

THE JOB AT A GLANCE

Reporting to the Team Leader: Clinical Claims Adjudication, the incumbent is responsible for providing support on the effective and efficient adjudication of disease and accident claims in line with COID Act and Non-COID VAPS policies (i.e., updating and reviewing ICD10 codes, pre-authorisation adjudication for out of hospital treatments, case management of all accident claims and claims estimates monitoring and management. The role requires an individual with critical thinking that is able to work independently and triangulate medical information to make claims decision on impairment assessment.

WHAT WILL YOU DO?

Claims processing and adjudication

• Review and update ICD10 codes on all claims in line with relevant protocols and accepted liability. Review medical reports and medical investigation report on the system for acceptance or rejection
• Liaise with medical service providers to submit outstanding medical reports in order to update claims progress status timeously and ensure that claims estimates remain within the acceptable estimates
• Evaluate treatment authorisation to either decline or approve the treatment authorisation request in line with the COIDA gazette. Ensure that the claims are properly case managed based on the treatment protocols that they are receiving versus the injury sustained or disease
• Manage costs associated with the authorization and claims estimates for all open claims
• Assess and update claims close to exceeding their Maximum Medical Improvement (MMI). Evaluate and analyse medical reports linked to claims and ensure claims are updated in accordance with medical reports received
• Communicate (via email and phone call) repudiated claims to claimants and provide reasons/rationale thereof for disease cases
• Adjudicate, Calculate and award  Permanent disability in line with delegation of authority policy, AMA Guide and COID Act instructions
• Adjudicate and recommend permanent disablement to medical advisors if disability impairment is above 10% for confirmation and once confirmation received, process the claim further and refer back to the claim owner
• Liaise and refer disease claims to medical advisors
• Manage high risk and complex  cases
• Close management and monitoring with claims above 500 000K estimated cost per claim
• Support claims team with complex claims queries from external stakeholders.

Attend to queries related to claims under management

• Provide Customer Services aligned to TCF (Treating Customer Fairly)
• Attend to   queries related to claims and escalate to medical advisors where needed.

Medical report writing

• Triangulate and summarise medical information received in order to refer claims to medical advisors and/or Technical Committee for claims decision (extension of MMI beyond 2years or impairment assessment above 10%).

WHAT YOU'LL BRING TO THE TABLE?

• NQF Level 7: Degree in Health Sciences (Nursing, Occupational Therapy and Physiotherapy, Clinical Associates
• Post graduate diploma in occupational health advantageous
• 3 – 5 years’ in-hospital clinical/case management/medical aid claims environment experience
• Group Life Insurance experience advantageous
• Occupational Health experience
• Clinical Judgement
• Medical/Financial services
• Insurance sector experience
• RE5 Certificate
• ICD10 knowledge
• MS Office
• COID Act and its instructions
• Occupational Health and Safety Act
• AMA Guide
• Disability Impairment Assessment
• Claims case management
• Stakeholder engagement
• Communication skills (who do they communicate with)
• Knowledge of business policies, processes and procedures, legal compliance.