Clinical Claims Adjudicator: Precise Disease Claims

Rand Mutual - RMA; Johannesburg; On-site; ZAR 420,000 - 660,000; Full time

Job summary

Rand Mutual Assurance in Johannesburg is seeking a Clinical Claims Adjudicator to support efficient adjudication of disease and accident claims under COID and COIDA policies. You will review ICD10 codes, medical reports, and treatment authorisation decisions, ensuring proper case management and adherence to guidelines.

You will liaise with medical providers, communicate repudiations with reasons, manage high-risk cases, and contribute to cost controls on open claims.

Responsibilities

• Review and update ICD10 codes on claims in line with protocols and accepted liability.
• Liaise with medical service providers to obtain outstanding medical reports and update claim progress.
• Evaluate treatment authorisation requests per COIDA gazette and ensure proper case management.
• Manage costs associated with authorization and claims estimates for open claims.
• Assess claims near Maximum Medical Improvement (MMI) and update per medical reports.
• Communicate repudiated claims and provide reasons to claimants for disease cases.
• Adjudicate and award permanent disability following authority policy and COID Act instructions.
• Refer disease claims to medical advisors as needed and support high-risk/complex cases.
• Close monitor claims with high estimated costs and assist with complex queries from stakeholders.

Job description

Rand Mutual Assurance in Johannesburg is seeking a Clinical Claims Adjudicator to support efficient adjudication of disease and accident claims under COID and COIDA policies. You will review ICD10 codes, medical reports, and treatment authorisation decisions, ensuring proper case management and adherence to guidelines.

You will liaise with medical providers, communicate repudiations with reasons, manage high-risk cases, and contribute to cost controls on open claims.