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Overview Join to apply for the Clinical Claims Analyst - Private Health Insurance role at Australian Unity. We want to be the most trusted wellbeing company in Australia, and this means our focus on wellbeing starts with our people. We support our employees Real Wellbeing so that they can better support our members and customers wellbeing journey. At Australian Unity were for Real Wellbeing. For us, Real Wellbeing means so much more than physical health. Its about your standard of living, your personal relationships and being connected to your community. Its about what you want to achieve in life, while having the security to get out and do what makes you happy. Were bold, warm and honest. We make a real difference to peoples wellbeing. We are on the lookout for a highly motivated registered nurse to join our team as the Clinical Claims Analyst within our Private Health Insurance business at Australian Unity. The Clinical Claims Analyst plays a vital role within the business by ensuring the accuracy, legitimacy and compliance of health insurance claims and clinical applications. Responsibilities Provide expert clinical assessment of claim information based on current disease management principles and an understanding of evidence based surgical and clinical pathways Document clinical assessment outcomes in Salesforce/Ensure with an appropriate level of rationale for decisions to ensure transparency in decision making Where required, assist the Compensation & Analysis team with complex pre-existing condition assessment, medical and accident reports Engage with the Hospital Assessing Team to transfer skills, knowledge, and insights to ensure the outgoing integrity of the hospital claims assessment process Contribute to guiding principles to ensure evidence-based decision making is the most up to date with the most current trends and technology Review ex-gratia applications for high-cost drugs, non listed prosthesis and other clinical/treatment items not ordinarily covered within fund rules ensuring compassionate, consistent and transparent funding decisions that do not adversely impact the business rovide clinical evidence as support for ex-gratia decisions (approval and denial) to ensure guiding principles remain current Maintain and share knowledge of new technology and other clinical developments coming through ex-gratia assessment process Where requested, or through queue management, provide additional support for internal business in regard to complex claims to ensure these claims are paid in line with contract and fund rules Maintain knowledge of current clinical pathways of treatment and utilise these when responding to claim queries Maintain detailed current knowledge of the hospital contracts and keep up to date with relevant clinical information impacting hospital contracts Conduct hospital/desktop audits as required according to Australian Unitys audit strategy framework Provide guidance and coaching to the new and existing members of the team in consultation with management What we are looking for essential skills & experience Bachelor of Health Science in Nursing & current registration with AHPRA as a Registered Nurse Relevant post-graduate qualification would be highly regarded Recent acute care clinical experience or equivalent Understanding of MBS, DRGs, Government legislation and regulations particularly the Private Health Insurance Act 2007 Not essential, however would make you stand out: Experience within the Private Health Insurance industry Extensive knowledge of surgical procedures, terminology and procedural classifications Experience working in a high dependency/critical care area (ie. ICU, CCU, ED, Theatre) of a private hospital Exposure to clinical pathway development within a healthcare organization Experience applying the principles of disease management in health promotion framework Skilled in assessing surgical documentation for accuracy, compliance, and medical necessity Understanding of project management and/or process improvement activities at a business unit or organisational level Whats on Offer You will enjoy a range of great employee benefits and rewards including: Competitive salary & Bonus Program Enjoy additional yearly Well-Being and Community leave days 14-week paid parental leave, with equal benefit for both parents Employee Referral Program Employee Assistance Program support and assistance for you and your partner at those times in life when you need it most. Maxxia Rewards - a great range of discounts and benefits at selected retail outlets, department stores, attractions, travel, cinemas, restaurants. Discounts across the Australian Unity business including Private Health Insurance, General Insurance + more! Available access to LinkedIn Learning courses through our great Learning platform For further benefits visit: Where to from here? Please contact Richard Maher, Talent Acquisition Practice Lead, for a confidential discussion or more details [email protected]. Australian Unity is an Equal Opportunity employer and we encourage applications from all members of the community, including people of Aboriginal and Torres strait Islander descent, culturally and linguistically diverse backgrounds and, mature aged people. #J-18808-Ljbffr