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Clinical Decision Specialist
3 weeks ago
We are seeking a highly motivated professional to fill the position of Clinical Claims Analyst within our organization.
Key Responsibilities:- Provide expert clinical assessment of claim information based on current disease management principles and an understanding of evidence-based surgical and clinical pathways.
- Document clinical assessment outcomes in Salesforce/Ensure with an appropriate level of rationale for decisions to ensure transparency in decision making.
- Where required, assist the Compensation & Analysis team with complex pre-existing condition assessment, medical and accident reports.
- Engage with the Hospital Assessing Team to transfer skills, knowledge, and insights to ensure the outgoing integrity of the hospital claims assessment process.
- Contribute to guiding principles to ensure evidence-based decision making is up-to-date with the most 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, ensuring compassionate, consistent, and transparent funding decisions that do not adversely impact the business.
- Provide clinical evidence as support for 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 process.
- Where requested, or through queue management, provide additional support for internal business in regard to complex claims to ensure these claims are paid in line with contract and fund rules.
- Maintain knowledge of current clinical pathways of treatment and utilize these when responding to claim queries.
- Maintain detailed current knowledge of the hospital contracts and keep up-to-date with relevant clinical information impacting hospital contracts.
- Conduct hospital/desktop audits as required according to Australian Unity's audit strategy framework.
- Provide guidance and coaching to the new and existing members of the team in consultation with management.
- Bachelor of Health Science in Nursing and 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.
- Competitive salary and bonus program.
- Enjoy additional yearly well-being and community leave days.
- 14-week paid parental leave, with equal benefit for both parents.
- Employee referral program.
- Employee assistance program – support and assistance for you and your partner at those times in life when you need it most.
- Maxxia rewards – a great range of discounts and benefits at selected retail outlets, department stores, attractions, travel, cinemas, restaurants.
- Discounts across the Australian Unity business, including Private Health Insurance, General Insurance, and more.
- Available access to LinkedIn learning courses through our great learning platform.
The ideal candidate will possess excellent communication and analytical skills, with the ability to work effectively in a fast-paced environment. If you are a motivated professional looking to make a difference in a dynamic organization, we encourage you to apply.
