Clinical Adviser & Claims Auditor job role summary
Job Overview:
This is an exciting opportunity to join our Health Insurance team as a Clinical Adviser & Claims Auditor. In this role, you will be responsible for measuring and testing procedures to improve overall efficiency, driving process improvement, quality focus, and implementing programs that deliver long-term benefits.
The successful applicant will also ensure the ongoing auditing of hospital, medical, and ancillary claims as required by the business, and as determined through the annual review of identified savings targets.
* Complete clinical advice and claims auditing in support of the claims department and assessors, driving continuous improvement of processes and systems, ensuring accuracy and compliance.
* Ensure audits conducted are compliant with PHI Rules, Contract Agreements, HICAPS Terms, Fund Rules, and other policy requirements of the organization.
* Assist the Customer Service Team Managers in implementing policies, procedures, guidelines, and audit schedules.
* Contribute to the organization's overall claims leakage strategic plan and objectives through planning own work and timely attendance to all delegated tasks and functions.
* Consider problems or issues that may arise and use lateral thinking to resolve or recommend solutions.
* Provide clinical advice to assessors and stakeholders where required.
* Liaise with hospital and provider billing teams as required to undertake the audit function effectively.
Requirements:
To be successful in this role, you will need:
* Experience working with PHI Hospital and Ancillary claim data.
* Succesful completion of recognized Medical Terminology course.
* Coding experience with knowledge of ICD-10-AM (11th edition), ACHI & ACS.
* Knowledge of private sector funding models.
* Degree Qualification in Health Information Management (HIM) highly regarded.
* Able to read and understand claims data and medical records, with the ability to determine where inconsistencies and/or outliers have occurred.
* Excellent organizational and time management skills, including demonstrated experience in coordinating input from multiple contributors.
* Effective consulting and stakeholder management skills.
Benefits:
We offer a range of benefits, including:
* Access to training and development opportunities to build on your current skills.
* Career development through internal mobility opportunities.
* The chance to work for a business helping millions of Australians and making a difference to someone's life every day.
* Additional leave days per year to recharge and refresh yourself.
* Wonderful Health and Wellbeing initiatives that support you.
* Supportive and inclusive managers.
About Us:
At [Company], we're proud to help guide, support, and protect the wellbeing of over 3.5 million Australians. As part of a leading organization, it is our ambition to engage one billion people to live Healthier, Longer, Better Lives by 2030.
We're different. Are you?
Join us in creating a healthier, more sustainable future for everyone.