MAU Clinical Care Coordinator

Position Purpose: To provide expert clinical assessment and decision making in relation to Ex gratia applications, regulatory (CMS) complaints, appeals, disputes and escalations.

Experience: 2-5 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration industry or similar.

Solid working experience with the following:

Appeals and Disputes Management

• Review and assess clinical appeals and disputes in line with scheme rules and clinical guidelines
• Analyse clinical documentation, treatment plans, and provider motivations
• Make evidence-based recommendations on benefit funding and clinical appropriateness
• Ensure turnaround times (TATs) are adhered to

CMS Case Management

• Manage complaints and escalations received from the Council for Medical Schemes (CMS)
• Compile detailed, accurate, and compliant cas...