Provider Assurance Specialist

Southern Cross Health Insurance; Auckland; Hybride; NZD 90 000 - 120 000; Plein temps

Avantages offerts par ce poste

Five days wellbeing leave

Health insurance for you and family

Life insurance cover and discounts on?

Extra parental leave benefits

Volunteer day and wellbeing programme

Résumé du poste

Southern Cross Health Insurance is seeking a Provider Assurance Specialist within the Healthcare Partnerships team in Auckland. You will work with a range of providers to ensure AP terms are understood and applied, and will guide investigations and audits to strengthen controls.

You’ll bring experience in claims assurance, FAWE investigations, and strong health-insurance product knowledge, with excellent communication and problem-solving skills to support robust provider governance.

Qualifications

• Experience across insurance, financial services, medical or health sector environments.
• Experience investigating fraud, abuse, waste and error (FAWE).
• Strong clinical literacy relevant to health insurance services.
• Knowledge of policy terms and Southern Cross products is advantageous.
• Well-developed critical thinking and problem-solving ability.
• Strong communication, training and influencing skills.

Responsabilités

• Run and oversee AP onboarding with providers and confirm obligations.
• Meet with providers to refresh AP understanding and discuss eligibility criteria and controls.
• Carry out quality assurance checks on provider controls.
• Investigate signals of potential claims leakage and analyse patterns.
• Advance investigations into formal audits and follow up corrective actions.
• Assess whether approvals and claims meet policy terms.
• Help design and improve our controls to keep leakage within appetite.
• Build relationships with Healthcare Partnerships, Member Services, Risk and Compliance.

Connaissances

Insurance experience

FAWE investigations

Clinical literacy

Health insurance product knowledge

Strong communication

Description du poste

About us

Southern Cross Health Insurance is shaping a healthier Aotearoa New Zealand. Our purpose is simple: empowering our members to live well for longer. We’re here to give peace of mind through timely access to quality care, inspire healthier living, and lead positive change across the health system. As a New Zealand-owned, member-based organisation, we’re building a future where wellbeing is at the heart of everything we do – delivering exceptional value for our members and creating an environment where our people thrive.

Now is an exciting time to join us. You’ll be part of a high-performing, values-driven team where people are at the heart of everything we do – and in return for your talent, you’ll have the opportunity to grow, make an impact, and be proud of the difference your work makes.

About the role

If you have a background in claims assurance, claims integrity, health audit or quality assurance – or experience investigating fraud, abuse, waste and error in a health or insurance setting – this new role could be a great fit.

Our Affiliated Provider (AP) programme gives healthcare providers a lot of agency to claim on behalf of our members. That low-friction approach works well for members, and relies on providers clearly understanding, and actively managing to, the terms of their AP agreement. This role helps make sure those terms are well understood and part of everyday practice.

As one of two new Provider Assurance Specialists in our Healthcare Partnerships team, you’ll work with a wide range of providers, from large groups to individual specialists, helping set clear expectations and understand how providers are set up to meet them.

Our provider onboarding process is going through an uplift along with increased focus on assurance and investigation activities – so you’ll have the opportunity to help shape the frameworks and process guides as they take form.

What you’ll do

• Work alongside our Partnership Managers to run and oversee our AP onboarding process, making sure providers understand and confirm their obligations.

• Meet with providers, in person or online, to refresh their understanding of the AP agreement and talk through how they’re set up – for example, how they assess eligibility criteria and exclusions, and the controls in their systems and processes.

• Carry out quality assurance checks on the controls providers have in place to manage to the terms of their agreement.

• Investigate signals of potential claims leakage – analysing patterns or anomalies in provider, surgeon and facility claiming behaviour, reviewing information in our systems, gathering clinical information and talking with providers to understand what’s happening.

• Where needed, move from investigation into a more formal audit approach, confirm findings with providers and follow up on corrective actions.

• Apply your knowledge to assess whether approvals and claims meet Southern Cross policy terms and conditions.

• Help design and continuously improve our controls, keeping claims leakage within Board appetite.

• Build strong working relationships with Healthcare Partnerships, Member Services, Risk and Compliance, and other teams across the business.

What you’ll bring

• Experience across insurance, financial services, medical, clinical or broader health sector environments – ideally in claims assurance, audit, integrity or investigations.

• Experience investigating fraud, abuse, waste and error (FAWE), and an understanding of best-practice approaches to managing integrity.

• Strong clinical literacy relevant to the healthcare services covered by health insurance.

• Strong technical knowledge of health insurance products and how policy terms and conditions are applied. Knowledge of Southern Cross products, our AP programme and claiming pathways is a real advantage.

• Well-developed critical thinking and the ability to solve complex problems with sound judgement.

• Strong communication, training and influencing skills – you can work through detailed conversations with providers in a way that’s professional, fair and constructive.

• The ability to engage credibly with a range of providers, from a large facility’s contract lead to a sole practitioner.

• Comfort working in a new and evolving area, and the adaptability to help shape processes as they develop.

Who we are

Ngākau nui. Āhurutanga. Tikanga.

Join a proud diverse team, that’s always there, always real, always true. If you thrive in a caring, honest and open culture, we think you’ll love working with us.

We know that it is our team’s culture and wellbeing that will drive us forward. That’s why we prioritise not only professional development opportunities but opportunities to thrive personally, too. We offer exceptional work/life balance and our employees are encouraged to — and rewarded for — living well.

What we offer you

Based at our Auckland office Te Kupenga, you’ll be supported to continually learn and grow your skills, share knowledge and ideas, and be part of a values-based culture where people are at its heart. Southern Cross employee benefits include:

• Five days of wellbeing leave per year

• Health insurance for you and your immediate whānau

• Life insurance cover and discounts on pet and travel insurance

• Extra parental leave benefits and financial wellbeing support

• Participation in our workplace wellbeing programme

That’s not all. Need more time to study, volunteer or support your whānau? You’ll have the opportunity to purchase flexi leave. Each year, you’ll also get to take part in a volunteer day, to contribute to a cause or community with your team.

This role is Auckland-based. Some travel to meet providers may be required. While we appreciate interest from candidates in other locations, we’ll manage remote working options on a case-by-case basis for the right candidate. Have questions? Check out our FAQs for help with the application and recruitment process.

We are proud to have taken the Pride Pledge, reflecting our commitment to inclusion and belonging. We also facilitate an active, employee‑led Diversity, Equity and Inclusion Forum, which includes our Rainbow Network, Māori Network, Pasifika Collective, and Neurodiversity and Whānau Support networks.

If you share our commitment and passion, we’d love to hear from you.