Clinical Claims Consultant

Clinical Claims Consultant - Oneplan Health Insurance

Location: Johannesburg, Gauteng

Department: Health Insurance Claims

Reporting to: Claims Manager

About Oneplan

Oneplan is one of South Africa's leading health insurance providers, committed to making quality healthcare more accessible and affordable. We are looking for a passionate and clinically skilled professional to join our Health Insurance team as a Clinical Claims Consultant.

Purpose of the Role

The Clinical Claims Consultant is responsible for assessing clinical claims through hospital authorisations, underwriting, case management, and claims evaluation. The role supports healthcare providers, policyholders, and internal stakeholders by ensuring clinical decisions align with policy rules, clinical protocols, and regulatory requirements.

This position plays a critical role in delivering exceptional client experiences while managing risk and ensuring appropriate healthcare utilisation.

Key Responsibilities

Clinical Authorisations & Claims Assessing & Case Management

• Assess and authorise hospital admissions and related healthcare services.
• Evaluate clinical information against policy benefits and utilisation management protocols.
• Conduct clinical risk assessments and case reviews.
• Review specialised claims including disability, death, and repatriation claims.
• Escalate complex clinical cases where required.

Underwriting

• Assess new dependent applications and underwriting requirements.
• Apply clinical underwriting guidelines and risk management principles.
• Ensure accurate and consistent underwriting decisions.

Client & Provider Support

• Engage with healthcare providers, hospitals, pharmacies, and policyholders.
• Assist clients with claims and authorisation queries.
• Educate clients and providers regarding policy benefits, exclusions, and processes.
• Resolve escalated clinical and claims-related enquiries.

Compliance & Quality Assurance

• Ensure all decisions comply with policy wording, clinical protocols, and legislation.
• Maintain accurate records and audit-ready documentation.
• Participate in clinical audits and quality reviews.
• Identify trends and recommend process improvements.

Operational Excellence

• Work within agreed service levels and turnaround times.
• Manage omni-channel interactions including telephonic, email, and WhatsApp communication.
• Contribute to a client-centric culture focused on first-contact resolution.

Minimum Requirements

Qualifications

• Registered Nurse (Preferred)
• Bachelor's Degree in Nursing, Health Sciences, Clinical Medicine, or related healthcare field
• Current registration with the relevant professional body (where applicable)
• RE5 qualification advantageous

Experience

• Minimum 2–3 years' experience in:
• Hospital case management
• Clinical risk management
• Managed healthcare
• Medical aid or health insurance
• Hospital authorisations
• Clinical claims assessment
• Utilisation review

Knowledge

• Health Insurance and Medical Scheme environments
• Clinical protocols and treatment guidelines
• Claims assessment and healthcare funding
• South African healthcare legislation
• Customer service and stakeholder management

Skills & Competencies

• Strong clinical assessment skills
• Clinical decision-making ability
• Problem-solving and analytical thinking
• Attention to detail
• Excellent communication skills
• Customer-centric mindset
• Ability to work independently
• High ethical standards
• Strong administrative and reporting skills

Why Join Oneplan?

• Be part of an innovative health insurance business.
• Work in a fast-paced and growing healthcare environment.
• Opportunity to make a meaningful impact on members' healthcare journeys.
• Competitive remuneration and career development opportunities.