Clinical Claims Adjudicator - Parktown at Rand Mutual - RMA

THE JOB AT A GLANCE

• As a Clinical Claims Adjudicator, you will be reporting to the Clinical Claims Adjudicator 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: Bachelor of Occupational Therapy or Physiotherapy
• 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
• Physiotherapy/Occupational Therapist/Occupational Nurse or Clinical Associate qualification

Closing date:  22 June 2023