Provider Assurance Specialist

Southern Cross Medical Care Society; Auckland; On-site; NZD 90,000 - 120,000; Full time

Benefits offered by this job

Wellbeing leave

Health insurance

Life insurance

Parental leave

Wellbeing programme

Flexi leave

Volunteer day

Job summary

Southern Cross Health Insurance is seeking a Provider Assurance Specialist within the Healthcare Partnerships team to oversee AP onboarding, refine controls, and investigate potential claims leakage. You will work with providers to ensure understanding of the AP agreement, assess eligibility, and review system controls while collaborating across risk, compliance and member services.

The role involves audits as needed, strong stakeholder engagement, and the ability to shape processes in a

Qualifications

• Experience across insurance, financial services, medical or health sector environments - ideally in claims assurance, audit, integrity or investigations.
• Experience investigating fraud, abuse, waste and error (FAWE) and understanding best-practice approaches to 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, AP programme and claiming pathways is advantageous.
• Well-developed critical thinking and the ability to solve complex problems with sound judgement.
• Strong communication, training and influencing skills to handle detailed conversations professionally and constructively.
• Ability to engage credibly with providers from large facilities to sole practitioners.
• Comfort working in a new, evolving area and readiness to shape processes as they develop.

Responsibilities

• Work with Partnership Managers to run and oversee the AP onboarding process, ensuring providers understand and confirm obligations.
• Meet with providers in person or online to refresh understanding of the AP agreement and assess eligibility criteria and controls.
• Carry out quality assurance checks on controls providers have to meet the agreement terms.
• Investigate signals of potential claims leakage by analysing patterns in provider, surgeon and facility claiming.
• Move from investigation to formal audit where needed and follow up on corrective actions.
• Assess whether approvals and claims meet Southern Cross policy terms and conditions.
• Help design and continually improve controls to keep claims leakage within board appetite.
• Build strong relationships with Healthcare Partnerships, Member Services, Risk and Compliance, and other teams.

Skills

Insurance experience

Financial services

Medical sector

Claims assurance

FAWE investigations

Clinical literacy

Policy knowledge

Communication

Stakeholder engagement

Adaptability

Job description

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.

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.