Clinical Claims Specialist

7 days ago

Melbourne, Victoria, Australia beBeeClaims Full time $95,000 - $125,000
Clinical Claims Expertise

We are seeking an experienced Clinical Claims Analyst to join our team. This exciting opportunity plays a vital role in ensuring the accuracy, legitimacy and compliance of health insurance claims and clinical applications within our Private Health Insurance business.

The successful candidate will be responsible for providing expert clinical assessment of claim information based on current disease management principles and an understanding of evidence-based surgical and clinical pathways.

Responsibilities
  • Provide detailed clinical assessments of claim information with appropriate rationale for decisions
  • Document clinical assessment outcomes in Salesforce/Ensure with an appropriate level of transparency
  • Support the Compensation & Analysis team with complex pre-existing condition assessments, medical and accident reports as required
  • Collaborate with the Hospital Assessing Team to transfer skills, knowledge, and insights to ensure the integrity of the hospital claims assessment process
  • Contribute to guiding principles to ensure evidence-based decision making is up-to-date with current trends and technology
  • Review ex-gratia applications for high-cost drugs, non-listed prosthesis and other clinical/treatment items not ordinarily covered within fund rules
  • Provide clinical evidence to support ex-gratia decisions (approval and denial) to ensure guiding principles remain current
  • Maintain and share knowledge of new technology and other clinical developments coming through ex-gratia assessment processes
  • Support internal business with complex claims to ensure they are paid in line with contract and fund rules as requested or through queue management
  • Stay up-to-date with relevant clinical information impacting hospital contracts
  • Conduct hospital/desktop audits as required according to Australian Unity's audit strategy framework
Requirements
  • Bachelor of Health Science in Nursing & current registration with AHPRA as a Registered Nurse
  • Relevant post-graduate qualification would be highly regarded
  • Recent acute care clinical experience or equivalent
  • Understanding of MBS, DRGs, Government legislation and regulations particularly the Private Health Insurance Act 2007

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