Clinical Healthcare Analyst

2 days ago

Melbourne, Victoria, Australia beBeeHealthcare Full time $90,000 - $120,000

Job Overview

We are seeking a highly motivated Clinical Healthcare Analyst to join our team. The successful candidate will play a vital role in ensuring the accuracy, legitimacy and compliance of health insurance claims and clinical applications.

The Clinical Healthcare Analyst will be responsible for assessing members' claims based on expert understanding of clinical disease pathways, extensive knowledge of surgical procedures and associated clinical pathways, and ensuring the clinical quality, consistency, and safety of these assessments.

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 a secure system, ensuring with an appropriate level of rationale for decisions to ensure transparency in decision making
  • 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 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
  • Maintain and share knowledge of new technology and other clinical developments coming through ex-gratia assessment process
  • 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 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 established audit strategy framework
  • Provide guidance and coaching to new and existing team members in consultation with management

Essential Skills & Experience

Bachelor of Health Science in Nursing & current registration with AHPRA as a Registered NurseRelevant post-graduate qualification would be highly regardedRecent acute care clinical experience or equivalentUnderstanding of MBS, DRGs, Government legislation and regulations particularly the Private Health Insurance Act 2007

Desirable Skills & Experience

Experience within the Private Health Insurance industryExtensive knowledge of surgical procedures, terminology and procedural classificationsExperience working in a high dependency/critical care area (ie. ICU, CCU, ED, Theatre) of a private hospitalExposure to clinical pathway development within a healthcare organizationExperience applying the principles of disease management in health promotion frameworkSkilled in assessing surgical documentation for accuracy, compliance, and medical necessityUnderstanding of project management and/or process improvement activities at a business unit or organisational level

What's On Offer

You will enjoy a range of great employee benefits and rewards including:

  • Competitive salary & 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 business including Private Health Insurance, General Insurance + more
  • Available access to LinkedIn Learning courses through our great Learning platform

About Us

We're a leading provider of wellbeing services, dedicated to making a real difference in people's lives. Our commitment to wellbeing starts with our employees, who are passionate about supporting our members and customers in achieving their goals.

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