Clinical Claims & Care Management Specialist

Oneplan.co.za; Sandton; On-site; ZAR 700,000 - 900,000; Full time

Job summary

OnePlan Health Insurance seeks a Claims & Case Management Specialist to lead clinical case management, pre-authorisation, and health claims assessment across the member journey. The role balances clinical judgement with policy interpretation to ensure appropriate authorisations and accurate claims decisions.

You will work closely with hospitals, doctors, and internal teams to optimise outcomes, accuracy, and customer care while upholding OnePlan policy benefits and claims rules.

Qualifications

• Experience in clinical case management and hospital-based care.
• Familiarity with health policy wording and claim rules.
• Ability to interpret policy benefits and assess utilisation.

Responsibilities

• Provide active clinical case management for members receiving hospital services.
• Coordinate pre-authorisation requests and verify policy benefits and conditions.
• Assess and adjudicate health claims against policy wording and benefit rules.
• Maintain accurate clinical notes and ensure audit trails.

Skills

Clinical case management

Hospital pre-authorisation

Health claims assessment

Policy interpretation

Customer care

Education

Nursing qualification

Tools

Mediscor

Job description

OnePlan Health Insurance seeks a Claims & Case Management Specialist to lead clinical case management, pre-authorisation, and health claims assessment across the member journey. The role balances clinical judgement with policy interpretation to ensure appropriate authorisations and accurate claims decisions.

You will work closely with hospitals, doctors, and internal teams to optimise outcomes, accuracy, and customer care while upholding OnePlan policy benefits and claims rules.