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Clinical Claims Manager

Industry: Credit Direct / Job Expires: 2018-04-26 21:30:38 / Location: Gauteng

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Reporting to the Claims Manager, the incumbent will be responsible to effectively and efficiently lead the processing and adjudication function of Injury on Duty and Occupational Disease claims, within the scope of the Compensation or Occupational Injuries and Diseases Act and other Insurance products, policies 

Qualifications and Experience required: 

  • COIDA in practice or Insurance qualification an advantage 
  • Qualification in Occupational Health Care 
  • SASOHN an advantage 
  • 5 to 10 years’ experience in Managed Healthcare / insurance claims / case management industry 
  • Exposure within an Occupations Disease Management Environment is advantageous 
  • 5 to 10 years’ experience in a management position, within a similar environment 

Key Areas of Responsibility 

  • Overall management of the medical team ensuring medical decisions are effectively, correctly and timeously made within the claims process 
  • Overall management of the severe injuries claims 
  • Overall management of the review process for validity and verification of cover 
  • Overall authorisation of calculation of permanent disability 
  • Act as liaison between medical and Claims team 
  • Overall management of the investigation of questionable claims with medical service providers. 
  • Overall confirmation of the calculation of Permanent Disability 
  • Overall management of the authorisation of Permanent Disability awards 
  • Overall management of the authorisation of Funeral Expenses 
  • Overall management of the authorisation of Widow’s Lump Sum Payment within authority limits 
  • Overall management of the Extension of Temporary Total Disablement based on medical evidence 
  • Overall accountability of ensuring correct IC10 codes are reviewed and updated 
  • Develop and implement standardised work procedures for the Claims Medical team 
  • Ensure the Claims Medical team works within the guidelines of relevant laws and standards 
  • Build strong working relationships with all medical service providers. 
  • Work closely with the Claims Managers on process improvement, ensuring medical decisions are efficiently and effectively carried out 
  • Provide reports and presentations on relevant information to management when directed 
  • Keep up to date with medical and occupational health knowledge through research and attending relevant approved courses / seminars 
  • Individually coach and develop direct reports to ensure high performing Claims Medical team 
  • Proactively identify and manage personnel problems to ensure an engaged team 
  • Implementation of performance management standards to ensure high calibre team 

Knowledge, Skills and Competencies 

  • Computer Literacy including MS Word, Excel and Outlook 
  • COIDA knowledge 
  • Extensive knowledge of medical terminology and healthcare tariffs 
  • Occupational Healthcare protocol 
  • Ability to work under pressure 
  • Attention to detail 
  • Excellent verbal and written communication skills 
  • Customer Service orientation 
  • Information management 
  • Time management 
  • Decision Making 
  • Team management 
  • Professional personal presentation 
  • Stress Management 

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