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 case responses within required timelines Liaise with internal stakeholders to gather relevant clinical and administr...