Ensure accurate and compliant underwriting decisions through thorough investigation, alignment with guidelines, analysis of underwriting criteria, and maintaining quality and compliance standards.
Requirements
- Matric certificate
- Underwriting Certification (Desirable)
- Bachelor degree or equivalent qualification in a relevant field such as healthcare administration, nursing, allied sciences, or equivalent medical-related discipline (Essential)
- Registration with the Health Professions Council of South Africa (HPCSA) or the South African Nursing Council (SANC) - (Desirable)
- Clinical knowledge (e.g., knowledge of anatomy and physiology, which helps in understanding medical conditions, treatments, and risks).
- Classification systems knowledge (e.g., familiarity with ICD-10 codes, which are used for medical classification and coding purposes).
- Basic understanding of Prescribed Minimum Benefits (PMBs).
- Knowledge of regulations set by the Council for Medical Schemes (CMS) and the Medical Schemes Act.
- Basic understanding of managed care processes and how they relate to underwriting.
- Awareness of operational processes that are connected to underwriting, ensuring coordination and efficiency within the broader healthcare system.
- Knowledge in using computer systems, software, and databases relevant to underwriting tasks.
- 2 - 3 years practical experience in Clinical Health Risk Management and or equivalent relevant experience
- Health underwriting and familiarity with non-disclosure processes, principles, and terminology
- Financial/Insurance industry (desirable)
Internal Process
- Conduct thorough medical assessments and apply clinical knowledge in a professional manner, ensuring accuracy and precision.
- Provide expert advice and support in underwriting, non-disclosure, and claims for moderate and complex assessments, effectively mitigating organisational risk.
- Make precise non-disclosure decisions for beneficiaries and dependents who fail to disclose health conditions upon re-joining the medical aid, adhering to the Medical Scheme Act, underwriting policy, and established standards, protocols, and guidelines.
- Implement condition-specific waiting periods following non-disclosure investigations.
- Investigate client queries within agreed service levels, delivering timely feedback to ensure utmost client satisfaction.
- Review claims and authorization history to identify any additional non-disclosed health conditions, enhancing accuracy in underwriting decisions.
- Develop and maintain productive relationships with peers and stakeholders, fostering collaboration and effective communication.
- Establish and uphold underwriting policies and guidelines, ensuring consistency, defensibility, and adherence to industry standards.
- Manage non-disclosure escalations within specified turnaround times, resolving issues promptly and efficiently.
- Foster positive relationships and partnerships with clients and key stakeholders, promoting trust and mutual growth.
- Efficiently plan, administer, and process beneficiaries' health information in alignment with performance objectives, ensuring data integrity and compliance.
- Collaborate with stakeholders in conducting underwriting and medical research in targeted areas, facilitating informed decision-making.
- Interact with clients competently and professionally, maintaining high-quality standards and delivering exceptional service.
- Establish and nurture relationships with clients, internal teams, and external stakeholders, fostering strong connections and mutual trust.
- Meet and exceed service level agreements applicable to clients and stakeholders, effectively managing and surpassing client expectations.
- Provide recommendations to enhance client service and ensure fair treatment within the realm of responsibility, promoting satisfaction and loyalty.
- Monitor turnaround times and quality standards, proactively resolving issues to enhance client service delivery.
- Provide accurate and timely resolution of client queries, utilising feedback to drive process improvements and optimise client service.
- Build strong relationships, share specialised knowledge, and demonstrate effective leadership, fostering collaboration and positive engagement.
- Continuously develop industry expertise and relevant knowledge, applying acquired insights to drive excellence.
- Positively influence and manage change, offering support and guidance when required, fostering adaptability and resilience.
- Foster a culture of innovation by involving colleagues and staff in the development and implementation of new ideas, driving continuous improvement.
- Contribute to work-centric thinking, productivity, service delivery, and quality management, promoting a high-performance work environment.
- Take ownership of driving career development, proactively pursuing growth opportunities and self-improvement.
- Implement and provide input into governance processes, systems, and legislation in the specialised area, ensuring compliance and efficiency.
- Escalate unresolved policy and governance compliance issues for investigation and resolution, promoting accountability and risk mitigation.
- Contribute to risk identification processes and communicate recommendations in the appropriate forum, enabling proactive risk management and mitigation.
