Process the loading of the condition-specific waiting period in line with underwriting guidelines as set out in the GEMS scheme rules and Medical Scheme Act (legislation) as set out by CMS.
You will be required to investigate non-disclosure cases and provide a decision in line with the underwriting guideline as set out in the GEMS scheme rules and Medical Scheme Act (legislation) as set out by CMS.
This role offers exciting and challenging opportunities and is aimed at a dynamic, performance-orientated, knowledgeable, and experienced individual, who is able to deliver quality outputs in a high deadline and client-orientated environment.
Analyze, update and effect changes to the underwriting and non-disclosure exceptions. Assess underwriting non-disclosure escalations accuracy and update accordingly.
Key Responsibilities:
Review claims and authorizations history to potentially identify additional non-disclosed health conditions.
Plan for administering, and processing beneficiaries’ health information effectively and efficiently in line with performance objectives.
Ability to build positive relationships and partnerships with clients and key stakeholders.
Create and maintain underwriting policy and guidelines to ensure consistency and make sure decisions are defendable.
Develop and maintain productive and collaborative working relationships with peers and stakeholders.
Provide underwriting, non-disclosure and claims advise and support related to moderate and complex assessment that involves risk for the organization.
Manage non-disclosure escalations within the stipulated turnaround time.
Medical assessment of cases and application of clinical knowledge in a highly professional manner.
Making accurate non-disclosure decisions for beneficiaries and their dependants who have not disclosed health conditions on re-joining the medical aid by applying the Medical Scheme Act (legislation), underwriting policy and Standards, protocols, and guidelines set.
Conduct underwriting and medical research in collaboration with stakeholders in areas that require investigation.
Apply conditions specific waiting periods post-non-disclosure investigation.
Investigate client queries within the agreed service level and ensure that client receives timeous feedback.
Required Education & Experience:
Strong knowledge and understanding of the Underwriting and Non-disclosure process.
Clinical preauthorization experience.
2 – 3 year’s Clinical Health Risk Management experience.
Clinical degree qualification or equivalent.
Strong communication skills.
Teamwork and Cooperation skills.
Medical aid industry experience and exposure would be an advantage.
Claims assessing experience or knowledge.
Ability to provide technical knowledge and advice to both internal and external customers to assist in decision-making.
Customer orientation.
Matric or Grade 12 qualification.
Medical industry knowledge.
Health underwriting and non-disclosure experience.
