Medical Advisor

2 weeks ago

Brisbane, Queensland, Australia Allianz Partners Full time
24892 | Physicians | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent

LOCATION:
Brisbane, Australia

Role purpose:

The Registered Nurse (RN) will play a key role within the International Health (OSHC & OVHC) team.

The RN will be responsible for reviewing and auditing medical claims, Treatment Guarantee and Guarantee of Payment requests including monitoring all high-cost cases (HCCs) (claims over $50K), while operating within policy and procedure guidelines.

The RN will also provide support, direction and education to non-clinical personnel within Allianz Worldwide Partners.


As part of their role in the International Health (OSHC & OVHC) team, the RN will be accountable and responsible for liaising with medical providers in both the Private and Public sectors to determine appropriate rates and charges for treatment and identifying opportunities for cost containment.


Key responsibilities:

Treatment Guarantee and Guarantee of Payment assessment:

  • Assess suitability of treatment/procedures requests from providers (Private and Public) and members to rule out any pre-existing conditions and/or confirm medically necessary treatments in accordance with the OSHC policy wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS) and Prostheses List
  • Issue Guarantee of Payments for treatment/procedures as requested from providers (Private and Public) and members in accordance with the OSHC policy wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS), Prostheses List and Public State Rates and Australian Health Service Alliance (AHSA) guidelines
  • Provide technical advice in terms on coverage for Preexisting (PE) conditions, Emergency treatment including any medically necessary treatments
  • Maintain a confidential relationship between health professionals and members in accordance with Privacy Legislation
  • Provide support, direction and education on related medical terms, treatments, and conditions to nonclinical personnel within Allianz Worldwide Partners.

Medical claims Adjudication and Cost Containment:

  • Review and assess all medical referrals/invoices to rule out PE conditions, Cosmetic or In Vitro Fertilisation (IVF) related treatments
  • Identify cost containment opportunities as a key part of the claims adjudication process within the International Health Controls and Governance processes
  • Understanding of the OSHC policies (Essential and Standard) wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS), Prostheses List and Public State Rates and Australian Health Service Alliance (AHSA) guidelines
  • Provide technical advice in terms on coverage for Preexisting (PE) conditions, Emergency treatment including any medically necessary treatments
  • Meet Service Level Agreement (SLA): Urgent (

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