Clinical Claims Adjudicator

SUMMARY:
Responsible for effective and efficient adjudication of COIDA and Non-COID (diseases and accidents)

POSITION INFO:

Main Purposes

The incumbent will be responsible for effective and efficient adjudication of COIDA and Non-COID (diseases and accidents) i.e. ICD10 codes, Authorisation of treatment, Temporal Total Disability, claims estimates, Management of Claims Maximum Medical Improvement, Percentage Disability calculations and recommend Whole Person Impairment percentage, etc.

Minimum Requirements

• National Diploma in Nursing/Allied Health (physio therapist, occupational therapist)/related field with additional certification. It must be NQF6
• RE5 Certificate
• 4 years’ clinical and ICD10 coding experience is required
• COIDA Experience (Advantage)
• Medical Aid experience / life insurance claims environment experience is a must

WHAT WILL YOU DO?

Claims processing and adjudication:

• Medical Management of claims aligned to treatment protocols and COIDA limits and generate Authorisation of treatment plans
• Manage costs associated with the authorization and claims Estimates
• Review and update ICD 10 codes based on First/Progress/Final Medical Reports/Investigation Results
• Review and update claims close to exceeding their Maximum Medical Improvement (MMI)
• Case manage claims with estimated PD of 10% and above to ensure correct liability decisions are made
• Manage, review and adjudicate all claims related to occupational diseases
• Referral of complex cases to the medical department for opinion and action accordingly
• Permanent Disability Assessments
• Pre-Authorisation treatment request adjudication 

Whole Person Impairment assessment:

• Calculate the Whole Person Impairment rate based on the American Medical Association (AMA) guidelines and the applicable COIDA Instructions
• Review claims and recommend for TTD Payment, Lump Sum payment or Pension

Attend to queries related to claims under management:

• Provide Customer Services aligned to TCF (Treating Customer Fairly)
• Assist with queries related to cases and claims under their control and escalate where needed

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