Health Claims & Case Management Specialist

Overview

Health Claims & Case Management Specialist Jobs in Sandton, Gauteng, South Africa at Oneplan.co.za

Title: Health Claims & Case Management Specialist

Company: Oneplan.co.za

Location: Sandton, Gauteng, South Africa

Claims & Case Management Specialist – Oneplan Health Insurance

Health Insurance | OnePlan Insurance | Johannesburg

Join the OnePlan Health Insurance Team

OnePlan 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 OnePlan 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 OnePlan teams.

Key Responsibilities

Clinical Case Management

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 OnePlan.
• 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 escalate 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.

Pre-Authorisation

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 escalate 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.

Health Claims Assessment

Assess health insurance claims accurately and consistently in accordance with OnePlan’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 reassessments where required.
• Identify potential duplicate claims, unusual utilisation, inconsistencies or claims requiring further investigation.
• Ensure declined or repudiated claims have an accurate, defensible and clearly documented reason.
• Support the resolution of claims queries, escalations and disputed decisions.
• Conduct staff claims audits and quality reviews to identify errors, inconsistencies and coaching opportunities.
• Provide feedback and support to improve claims assessment quality and consistency.
• Maintain claims accuracy and turnaround times in accordance with agreed operational SLAs.

Clinical Risk & Quality

As part of the wider Claims and Clinical Risk function, the Specialist will also:

• Apply a consistent approach to clinical necessity, policy interpretation and benefit utilisation.
• Identify potential fraud, waste, abuse, over-servicing or inappropriate utilisation and escalate concerns for investigation.
• Identify recurring claims, authorisation or provider trends and escalate emerging risks.
• Participate in clinical and claims case reviews where required.
• Contribute to improving claims and pre-authorisation procedures, clinical protocols and SOPs.
• Support a customer-centric approach to claims decisions, ensuring that decisions are both technically correct and clearly explained.

Healthcare Provider Engagement

A significant component of the role involves working directly with external healthcare providers.

The Specialist will:

• Build professional working relationships with hospitals, doctors, pharmacies and other healthcare providers.
• Liaise with providers regarding clinical information, authorisations, claims and benefit queries.
• Work with hospitals within OnePlan’s existing provider arrangements, including Netcare, Mediclinic and Life Healthcare.
• Support the resolution of provider queries and billing or authorisation discrepancies.
• Ensure provider interactions are professional, accurate and focused on achieving appropriate outcomes for the member.

Minimum Requirements

• Relevant clinical or healthcare qualification.
• Nursing qualification and current or previous clinical experience would be highly advantageous.
• Experience within health insurance, medical schemes, managed care, hospital case management, pre-authorisation or health claims is strongly preferred.
• Practical understanding of hospital admissions, medical terminology, clinical documentation and healthcare claims.
• Experience reviewing clinical motivations and medical reports.
• Understanding of policy benefits, limits, exclusions and claims assessment principles.
• Previous exposure to healthcare provider engagement and hospital environments.

Experience with healthcare claims adjudication platforms, including Mediscor or similar electronic adjudication systems, will be advantageous.

Skills & Competencies

The successful candidate should demonstrate:

• Strong clinical reasoning and assessment skills.
• Ability to interpret policy wording and apply benefit rules consistently.
• Sound judgement when assessing medical necessity and healthcare utilisation.
• Strong attention to detail and claims accuracy.
• Ability to analyse medical and claims information and identify potential risk.
• Strong written and verbal communication skills.
• Confidence engaging with doctors, hospitals and other healthcare professionals.
• Strong problem-solving and decision-making capability.
• Ability to manage multiple cases and priorities in a high-volume environment.
• Customer-centric approach while maintaining appropriate clinical and financial controls.
• High levels of integrity, accountability and confidentiality.
• Ability to work collaboratively within a multidisciplinary claims environment.

What Success Looks Like

Success in this role means delivering accurate, timely and clinically appropriate decisions while ensuring that members receive the benefits to which they are entitled under their OnePlan policy.

The Claims & Case Management Specialist will contribute directly to improving the member experience, strengthening clinical risk management, reducing claims errors and leakage, and ensuring sustainable and responsible management of healthcare claims.