Clinical Assessor

3 days ago

Greater Adelaide SA, Australia Bupa Full time

**The heart of the role**:
Clinical assessors review medical claims to determine whether the treatments or services provided are medically necessary and covered under the patient's insurance policy, working with healthcare providers to coordinate care and ensure that patients receive appropriate and cost-effective treatments. They identify potential cases of fraud or abuse by reviewing claims and medical records for inconsistencies or irregularities. Interacting with healthcare providers to discuss clinical decisions, provide feedback, and resolve issues related to coverage and reimbursement

Assessors are involved in the delivery of timely customer solutions and deliberations in accordance with Bupa's fund rules, Private Health Insurance legislation, product coverage and Bupa’s policies, procedures and service standards.

Their role is essential in balancing the need to provide quality patient care with the financial and regulatory constraints of health insurance. Ensuring that insurance resources are used effectively while maintaining adherence to clinical and ethical standards.

**Key accountabilities include**:

- Deliver accurate, timely and efficient clinical assessment of all claims managed by the team
- Ensure considerate, professional, empathetic communication with customers, health care practitioners and other Bupa teams and people that may be touched by these processes
- Act within "Eligibility Line" roster requirements, completing phone calls and answering queries from providers and other areas of the business requiring clinical assessment
- Identify and recommend opportunities for process and functional improvements that support this review
- Assure legal and regulatory compliance and adhere to internal operating procedures
- Other duties as directed by Team Leader, Medical Advisor or Management

**Additional Information about the role**:

- Start Date Jan/Feb 2025
- The role will be based on-site at our Adelaide office for the first 4 weeks, once you and your team leader agree you have settled well, you will be able to work remotely, with a requirement to attend the office twice a week.

**We’ve got your back**

The special thing about Bupa is that care is at our core and will always be a part of how we operate. Extending that, we want our people to feel they are benefiting from Bupa’s purpose: so that everyone is supported to live the healthiest and happiest version of themselves. Simply put, this is what wellbeing means at Bupa.

Our global wellbeing program covers all aspects of our health - from mental and physical, to financial, social and environmental wellbeing. We are providing health benefits, information and support for everyone who works here, no matter their role.

**Our range of benefits include**:

- Fully subsidised health insurance products - How good is that
- Discounts on travel, car and home products, as well as discounts on Bupa services such as Dental and Optical, skin checks and vaccinations
- Discounted products and services via our extensive partner network, like Apple, Endota Spa, New Balance, Garmin, JB Hi Fi,
- An additional annual leave day for you to focus on your wellbeing
- An additional volunteer day each year for you to give back to your community

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