Clinical Claims Adjudicator: Impairment & Case Management

Rand Mutual - RMA; Parktown (NC); On-site; USD 21,000 - 31,000; Full time

Job summary

Rand Mutual Assurance is seeking a Clinical Claims Adjudicator to support adjudication of disease and accident claims in line with COID Act and Non-COID VAPS policies. The role involves updating ICD10 codes, pre-authorisation adjudication, and managing complex claims with independent critical thinking to assess impairment.

You will coordinate with medical service providers, assess treatment authorisation requests, and ensure accurate claims management.

Qualifications

• Requires a Health Sciences degree at NQF level 7 and RE5 certification.
• Postgraduate diploma in occupational health is advantageous.
• Experience in medical claims and COID/FAIS framework is essential.

Responsibilities

• Process and adjudicate disease and accident claims in line with COID Act and VAPS policies.
• Review ICD10 codes and liaise with service providers for outstanding reports.
• Evaluate authorisation requests and ensure proper case management of claims.
• Manage costs related to authorisation and claims estimates for open claims.
• Assess claims nearing Maximum Medical Improvement and update accordingly.
• Communicate repudiated claims with clear rationale to claimants and maintain records.

Skills

Communication skills

Stakeholder engagement

Clinical judgement

Medical aid/insurance experience

ICD10 knowledge

Education

NQF Level 7: Health Sciences degree

Postgraduate diploma in occupational health

RE5 certificate

Tools

MS Office

Job description

Rand Mutual Assurance is seeking a Clinical Claims Adjudicator to support adjudication of disease and accident claims in line with COID Act and Non-COID VAPS policies. The role involves updating ICD10 codes, pre-authorisation adjudication, and managing complex claims with independent critical thinking to assess impairment.

You will coordinate with medical service providers, assess treatment authorisation requests, and ensure accurate claims management.