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Medical Advisor

4 months ago

Brisbane, Queensland, Australia Allianz Partners Full time

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

The RN will be responsible for reviewing and adjudicating all medical claims, request for treatment and Guarantee of Payments 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 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 include:

Treatment Guarantee and Guarantee of Payment assessment:

  • Assess suitability of treatment/procedures requests for providers (Private and Public sectors) and members to confirm Guarantee of Payment for medical services in accordance with the OSHC & OVHC policy wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS) and Private Healthcare Prostheses guidelines
  • 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.
  • Liaise with the Chief Medical Officer for medical advice
  • Meet Service Level Agreement (SLA)

Medical claims Adjudication and Cost Containment:

  • Review and assess all medical claims/invoices in accordance with the OSHC & OVHC policy wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS) and Private Healthcare Prostheses guidelines
  • Identify cost containment opportunities as a key part of the claims adjudication process within the International Health Controls and Governance processes
  • Familiar with the Overseas Student & Overseas Visitors Health Care policies wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS), Private Healthcare Prostheses guidelines, Public State Rates and Australian Health Service Alliance (AHSA) guidelines
  • Provide technical advice on certain medical conditions, services and treatments that are identified as a Preexisting medical condition
  • Maintain a confidential relationship between health professionals and members in accordance with Privacy Legislation

High-Cost Case (HCC) Management:

  • Review and assess all medical claims/invoices in accordance with the OSHC & OVHC policy wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS) and Private Healthcare Prostheses guidelines
  • Assess suitability of treatment/procedures requests for providers (Private and Public sectors) and members to confirm Guarantee of Payment for medical services above $50K in accordance with the OSHC & OVHC policy wording, Medicare Benefit Schedule (MBS), Pharmaceutical Benefit Schedule (PBS) and Private Healthcare Prostheses guidelines
  • Identify cost containment opportunities as a key part of the claims adjudication process within the International Health Controls and Governance processes
  • Provide technical advice on certain medical conditions, services and treatments that are identified as a Preexisting medical condition
  • Maintain a confidential relationship between health professionals and members in accordance with Privacy Legislation

Relationship Management

  • Maintain relationships with both external and internal stakeholders
  • Ensure administration requirements of the role are performed efficiently and effectively to meet deadlines and
  • Contribute to the continuous improvement of administration and reporting processes
  • Contribute to the reporting requirements for International Health when requested
  • Assist in the preparation of presentations, proposals and reports

Data Collation and Completion:

  • Record referrals reviewed in the Medical Specialist Tracking report
  • Record claims/new cases within the highcost spreadsheet

Experience and Qualifications:

  • Tertiary qualifications recognised by the regulation authority (AHPRA) as a registered nurse and experience in the primary health care sector
  • Emergency nursing experience is highly regarded but not essential
  • A commitment to ongoing professional development.
  • Ensure nursing registration remains current and restrictions free.

Essential Skills:

  • Excellent PC skills (keyboard entry/accuracy) including basic knowledge of Microsoft word, excel and PowerPoint programs
  • Possess excellent verbal, nonverbal and written communication skills when dealing with different levels of staff throughout Allianz Partners as well as individuals external to the department.
  • Good problemsolving capabilities with an advanced diagnostic and methodical approach.

Professional:

  • Proven high level of