Health Claims & Case Management Specialist

Health Insurance | One Plan Insurance | Johannesburg

Join the One Plan Health Insurance Team

One Plan is looking for an experienced and customer-focused Claims & Case Management Specialist to join our Health Insurance team.

This is a multidisciplinary role combining clinical case management, hospital pre-authorisation and health claims assessment
. The successful candidate will play an important role in supporting members throughout their healthcare journey while ensuring that treatment, authorisations and claims are assessed appropriately and in accordance with One Plan policy benefits, clinical requirements and claims rules
.

The role requires someone who can balance clinical judgement, policy interpretation, claims accuracy and customer care
, while working closely with hospitals, healthcare professionals and internal One Plan teams.

Provide active case management and clinical oversight for members receiving hospital and related healthcare services.

Key responsibilities include:

• Follow up on hospital admissions and obtain regular clinical progress updates and discharge records
  .
• Monitor admitted members and maintain accurate and current case management records.
• Liaise with hospitals, treating doctors and other healthcare providers regarding changes in treatment, level of care, clinical requirements and available policy benefits
  .
• Coordinate hospital care and facilitate communication between the member, healthcare provider and One Plan.
• Assist with hospital transfers
  , including assessment of medical necessity and coordination with the relevant facilities and providers.
• Conduct first-line clinical reviews of cases and elevate complex, high-risk or high-cost cases where appropriate.
• Review the appropriateness and medical necessity of proposed treatment and continued hospitalisation.
• Monitor length of stay (LOS) and changes in level of care and identify cases requiring further clinical review.
• Identify high-cost, complex or potentially high-risk cases for proactive case management.
• Obtain outstanding clinical information required to support ongoing authorisation and claims decisions.
• Support appropriate discharge planning and continuity of care where required.
• Maintain clear clinical notes, decisions and supporting documentation to ensure a complete audit trail.

Assess and manage requests for healthcare services requiring prior authorisation under the member's policy.

Key responsibilities include:

• Review and assess pre-authorisation requests for hospital admissions, procedures and other applicable healthcare services.
• Verify active policy/membership status and confirm the member's available benefits, limits, waiting periods and applicable policy conditions
  .
• Assess requests against policy benefits, clinical information and applicable utilisation rules.
• Obtain medical history, clinical motivations, diagnostic information and medical reports where additional information is required.
• Liaise directly with hospitals, doctors and other healthcare providers to obtain information required to make an informed authorisation decision.
• Communicate approvals, partial approvals, declined requests or repudiations clearly and accurately to members and healthcare providers.
• Ensure reasons for decisions are properly documented and communicated in accordance with policy wording and internal procedures.
• Assist with hospital transfers and the coordination of hospital care where required.
• Identify urgent, complex, unusual or high-cost requests and elevate these for clinical or management review.
• Ensure pre-authorisation decisions are completed within agreed turnaround times and service levels
  .
• Maintain complete and accurate authorisation records and supporting documentation.

Assess health insurance claims accurately and consistently in accordance with One Plan's policy wording, benefits and claims procedures.

Key responsibilities include:

• Review and assess health claims against the applicable policy wording and benefit rules
  .
• Verify policy and member eligibility at the date of service.
• Confirm applicable benefits, limits, exclusions, waiting periods and previous utilisation.
• Validate supporting documentation and information required to assess the claim.
• Calculate the correct payable benefit amount in accordance with policy rules and available limits.
• Approve, partially approve, decline or refer claims within the incumbent's delegated authority.
• Process claim adjustments, corrections and…