Clinical Claims Adjudication

**THE JOB AT A GLANCE**

As a Clinical Claims Adjudication, you will be reporting to the Clinical Claims Adjudication Team Leader, you will be responsible for effective and efficient adjudication of COIDA and Non-COID (diseases and accidents) i.e. ICD10 codes, Authorisation of treatment, TTD (Temporal Total Disability), claims estimates, Management of Claims MMI (Maximum Medical Improvement), PD (Percentage Disability) calculations and recommend Whole Person Impairment percentage, etc.

**WHAT WILL YOU DO?**

**Claims processing and adjudication**
- Medical Management of claims aligned to treatment protocols and COIDA limits and generate Authorisation of treatment plans
- Manage costs associated with the treatment authorization and claims Estimates
- Review and update ICD 10 codes based on First/Progress/Final Medical Reports/Investigation Results
- Review and update claims close to exceeding their Maximum Medical Improvement (MMI)
- Case manage claims with estimated PD of 10% and above to ensure correct liability decisions are made
- Manage, review and adjudicate all claims related to occupational diseases
- Referral of complex cases to the medical department for opinion and action accordingly.
- Contribute and make input on claims complaints.
- Mentor junior CCA staff on claims management.

**Whole Person Impairment assessment**
- Identify Calculate the Whole Person Impairment rate based on the American Medical Association (AMA) guidelines and the applicable COIDA Instructions
- Review claims and recommend for TTD Payment, Lump Sum payment or Pension

**Attend to queries related to claims under management**
- Provide Customer Services aligned to TCF (Treating Customer Fairly)
- Assist with queries related to cases and claims under their control and escalate where needed
- Engage and/or provide training to relevant stakeholders

**WHAT YOU'LL BRING TO THE TABLE?**
- NQF Level 7: Registered Nurse with Occupational Health Background
- 3 to 5 years clinical experience.
- 3 to 5 years’ insurance/medical aid claims environment experience
- Group Life Insurance experience advantageous
- COIDA Experience
- Medical/Financial services
- Insurance sector experience
- RE5 Certificate
- ICD10 coding

**WHAT WILL YOU GET IN RETURN?**

We offer great opportunities for personal and professional development in a stable company that’s 127 years strong. The role comes with a competitive salary package and various benefits. Flexible work arrangements (combination of remote and in the office). Furthermore, you will be a part of a dedicated group of colleagues who value teamwork and collaboration.

**Turnaround time**

**Closing date: 8 November**

**Our Commitment to transformation**:

- NQF Level 7: Registered professional nurse/Allied Health/related field with additional certification
- 3 to 5 years clinical experience.
- 3 to 5 years’ insurance/medical aid claims environment experience
- Group Life Insurance experience advantageous
- COIDA Experience
- Medical/Financial services
- Insurance sector experience
- RE5 Certificate
- ICD10 coding