Clinical Underwriter TALENT POOL MMH251118-13

Clinical Underwriter Talent Pool MMH Ensure accurate and compliant underwriting decisions through thorough investigation, alignment with guidelines, analysis of underwriting criteria, and maintaining quality and compliance standards. Requirements Underwriting Certification is advantageous. Bachelor degree or equivalent qualification in a relevant field such as healthcare administration, nursing, allied sciences, or equivalent medical-related discipline is essential. Registration with the Health Professions Council of South Africa (HPCSA) or the South African Nursing Council (SANC) is advantageous. 2 - 3 years practical experience in Clinical Health Risk Management and or equivalent relevant experience. Health underwriting and familiarity with non-disclosure processes, principles, and terminology. Financial/Insurance industry experience (desirable). Clinical knowledge (e.g., knowledge of anatomy and physiology, which helps in understanding medical conditions, treatments, and risks). Classification systems knowledge (e.g., familiarity with ICD-10 codes). Basic understanding of Prescribed Minimum Benefits (PMBs). Knowledge of regulations set by the Council for Medical Schemes (CMS) and the Medical Schemes Act. Basic understanding of managed care processes and how they relate to underwriting. Awareness of operational processes that are connected to underwriting, ensuring coordination and efficiency within the broader healthcare system. Knowledge in using computer systems, software, and databases relevant to underwriting tasks. Duties and Responsibilities Process Conduct thorough medical assessments and apply clinical knowledge in a professional manner, ensuring accuracy and precision. Provide expert advice and support in underwriting, non-disclosure, and claims for moderate and complex assessments, effectively mitigating organisational risk. Make precise non-disclosure decisions for beneficiaries and dependents who fail to disclose health conditions upon re-joining the medical aid, adhering to relevant regulations and established standards. Implement condition-specific waiting periods following non-disclosure investigations. Investigate client queries within agreed service levels, delivering timely feedback to ensure utmost client satisfaction. Review claims and authorization history to identify any additional non-disclosed health conditions, enhancing accuracy in underwriting decisions. Develop and maintain productive relationships with peers and stakeholders, fostering collaboration and effective communication. Establish and uphold underwriting policies and guidelines, ensuring consistency, defensibility, and adherence to industry standards. Manage non-disclosure escalations within specified turnaround times, resolving issues promptly and efficiently. Foster positive relationships and partnerships with clients and key stakeholders, promoting trust and mutual growth. Efficiently plan, administer, and process beneficiaries' health information in alignment with performance objectives, ensuring data integrity and compliance. Collaborate with stakeholders in conducting underwriting and medical research in targeted areas, facilitating informed decision-making. Interact with clients competently and professionally, maintaining high-quality standards and delivering exceptional service. Client Establish and nurture relationships with clients, internal teams, and external stakeholders, fostering strong connections and mutual trust. Meet and exceed service level agreements applicable to clients and stakeholders, effectively managing and surpassing client expectations. Provide recommendations to enhance client service and ensure fair treatment within the realm of responsibility, promoting satisfaction and loyalty. Monitor turnaround times and quality standards, proactively resolving issues to enhance client service delivery. Provide accurate and timely resolution of client queries, utilising feedback to drive process improvements and optimise client service. People Build strong relationships, share specialised knowledge, and demonstrate effective leadership, fostering collaboration and positive engagement. Continuously develop industry expertise and relevant knowledge, applying acquired insights to drive excellence. Positively influence and manage change, offering support and guidance when required, fostering adaptability and resilience. Foster a culture of innovation by involving colleagues and staff in the development and implementation of new ideas, driving continuous improvement. Contribute to work-centric thinking, productivity, service delivery, and quality management, promoting a high-performance work environment. Take ownership of driving career development, proactively pursuing growth opportunities and self-improvement. Finance Implement and provide input into governance processes, systems, and legislation in the specialised area, ensuring compliance and efficiency. Escalate unresolved policy and governance compliance issues for investigation and resolution, promoting accountability and risk mitigation. Contribute to risk identification processes and communicate recommendations in the appropriate forum, enabling proactive risk management and mitigation. Seniority Level Mid-Senior level Employment Type Full-time Job Function Finance and Sales #J-18808-Ljbffr