Clinical Claims Analyst

**What Makes Us, Us**

We want to be the most trusted wellbeing company in Australia, and this means our focus on wellbeing starts with our people. We support our employees’ Real Wellbeing so that they can better support our members’ and customers’ wellbeing journey.

At Australian Unity we’re for Real Wellbeing. For us, Real Wellbeing means so much more than physical health. It’s about your standard of living, your personal relationships and being connected to your community. It’s about what you want to achieve in life, while having the security to get out and do what makes you happy.

We’re** bold, warm** and** honest.**We make a real difference to people’s wellbeing**.**

**Our Opportunity**

We are on the lookout for a highly motivated registered nurse to join our team as the Clinical Claims Analyst within our Private Health Insurance business at Australian Unity.

As a member of the Claims Integrity team, key qualifications and experience in critical care (i.e. ICU, operating theatre or ED) and/or the private health industry, will enable the analyst to provide support and insights to key stakeholders across the business involved in claims analysis, provider relations, and quality assurance. The role will be accountable for the assessment of 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 of the role include, but are not limited to:

- 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 the most up to date with the most current trends and technology
- rovide 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 utilise 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

**What we are looking for - essential skills & experience**
- 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

Not essential, however would make you stand out:

- Experience within the Private Health Insurance industry
- Extensive knowledge of surgical procedures, terminology and procedural classifications
- Experience working in a high dependency/critical care area (ie. ICU, CCU, ED, Theatre) of a private hospital
- Exposure to clinical pathway development within a healthcare organization
- Skilled in assessing surgical documentation for accuracy, compliance, and medical necessity
- Understanding 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 Australian Unity business including Private Health Insurance, General Insurance + more
- Available access to LinkedIn Learning courses through our great Learnin