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Clinical Claims Analyst

2 weeks ago

Melbourne, Victoria, Australia Australian Unity Full time $80,000 - $120,000 per year

Company description:

Australian Unity Group Services Pty Ltd

Job description:

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.

The Clinical Claims Analyst plays a vital role within the business by ensuring the accuracy, legitimacy and compliance of health insurance claims and clinical applications.

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.

KPI's will be based on the consistent application of clinically robust decision making, accurately validating the quality of hospital documentation, and performing within specified time constraints. This role extends to performing onsite hospital documentation audits for assessment of selected high-risk episodes of care if required.

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

  • 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

  • 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
  • Experience applying the principles of disease management in health promotion framework
  • 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 Learning platform

For further benefits visit:

Where to from here?

Please contact Richard Maher, Talent Acquisition Practice Lead, for a confidential discussion or more details -

Australian Unity is an Equal Opportunity employer and we encourage applications from all members of the community, including people of Aboriginal and Torres strait Islander descent, culturally and linguistically diverse backgrounds and, mature aged people.