Role Summary
Medical Advisor (Registered Nurse) Location: Brisbane
Team: International Health (OSHC & OVHC)
Core Purpose
* Assess and approve Guarantee of Payment (GOP) and treatment requests
* Adjudicate medical claims aligned to policy, MBS/PBS, and guidelines
* Manage high-cost cases (>$50K) with clinical and financial oversight
* Provide clinical guidance across the business
* Drive cost containment and governance
Key Responsibilities
* Treatment Approval (GOP)
* Evaluate treatment requests against policy & Medicare frameworks
* Liaise with providers (public & private)
* Support internal teams with clinical interpretation
* Meet strict SLAs (48–72 hrs)
* Claims Adjudication & Cost Management
* Review medical invoices and claims
* Apply MBS, PBS, AHSA, prostheses rules
* Identify cost‐saving opportunities
* Advise on pre‐existing conditions
* Maintain accurate documentation systems
* High‐Cost Case (HCC) Management
* Oversee complex claims >$50K
* Collaborate with Chief Medical Officer
* Attend case reviews & manage large exposures (>$100K)
* Ensure compliance with longer SLAs (5–30 days)
* Stakeholder & Relationship Management
* Work with hospitals, providers, and internal teams
* Contribute to reporting and continuous improvement
* Support presentations and business updates
* Data & Reporting
* Track referrals, cases, and high‐cost claims
* Maintain SLA compliance across workflows
Technical & Clinical Expertise
* Strong understanding of MBS, PBS, OSHC & OVHC policies, and private/public hospital charging
* Ability to assess treatment appropriateness, clinical necessity, and cost efficiency
Ideal Candidate Profile
* Must‐Have
* Registered Nurse (AHPRA, unrestricted)
* Primary care or hospital experience
* Strong analytical and decision‐making capability
* Excellent communication skills (clinical & non‐clinical translation)
* Ability to manage workload under pressure
* Highly Regarded
* Emergency nursing background
* Experience in health insurance, claims or utilisation review, or case management
What Makes This Role Unique
* Blend of clinical & corporate decision‐making
* High exposure to complex cases and cost strategy
* Significant influence on medical spend and outcomes
* Opportunity to transition from bedside to strategic healthcare role
Position Type
Full‐Time, Temporary, Non‐Executive, Professional
EEO Statement
We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, social class, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulations.
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