Clinical Consultant – Medical Insurance

Job Description: Clinical Consultant – Medical Insurance

Department

Medical Insurance Claims and Customer Service

Reports To

Manager: Medical Insurance Claims and Customer Service

Role Purpose

The Clinical Consultant is responsible for the clinical assessment, management and coordination of medical cases, authorisations and claims to ensure members receive appropriate, cost-effective and clinically necessary healthcare in accordance with policy benefits, clinical protocols and company guidelines.

The role supports medical risk management through clinical review of inpatient and outpatient treatment, medical reports, pre-authorisations, hospital admissions, evacuations, repatriations and claims, while supporting quality service delivery and financial sustainability.

As OracleMed provides a 24-hour medical assistance service, the successful candidate will participate in rotational shifts, weekends, public holidays and after-hours standby as operationally required.

Key Responsibilities

Clinical Case Management

• Assess and manage inpatient and outpatient cases from admission through discharge; review medical reports, investigations and treatment plans.

• Ensure treatment is clinically appropriate, evidence-based and aligned with protocols and policy benefits; monitor length of stay and discharge planning.

• Coordinate medical evacuations and repatriations and escalate complex/high-cost cases to the Clinical Manager or Medical Advisor.

Medical Authorisations

• Assess and process pre-authorisations for admissions, procedures, specialised investigations and prescribed treatments.

• Approve, decline or refer requests based on policy rules, clinical guidelines and medical necessity, including consumables, specialised equipment and high-cost medication; document decisions.

Claims Risk Management

• Review claims for medical necessity and benefit eligibility; identify potential fraud, abuse, over-servicing or inappropriate billing.

• Support underwriting-related clinical reviews and cost-containment initiatives while maintaining quality patient outcomes.

Customer and Provider Support

• Provide professional clinical advice to members, healthcare providers, brokers and corporate clients; respond to benefit and authorisation enquiries.

• Liaise with hospitals and treating practitioners for additional clinical information and ensure communication meets agreed SLAs.

Quality, Compliance and Operations

• Maintain accurate clinical records and confidentiality; comply with company policies, medical insurance regulations and clinical governance standards; participate in audits and continuous improvement.

• Participate in after-hours standby, rotational shifts, weekends and public holidays; assist during peak periods, emergencies and departmental projects.

Minimum Requirements

Qualifications : Grade 12; Diploma or Degree in Nursing; current SANC registration. Additional Critical Care, Emergency, Trauma, ICU or Theatre Nursing qualifications advantageous.

Experience : Minimum 3–5 years’ post-registration clinical nursing experience. Medical insurance, managed healthcare, case management, medical assistance, authorisations or claims experience advantageous. ICU, Emergency, High Care, Theatre or Medical/Surgical experience preferred.

Knowledge, Skills and Competencies

Sound clinical assessment and decision-making; medical insurance benefits and managed healthcare principles; hospital utilisation review and case managementICD-10/CPT/CCSA knowledge advantageous; analytical and problem-solving ability; excellent communication and customer service; accuracy and attention to detail; computer literacy; ability to manage multiple priorities; clinical judgement, critical thinking, integrity, accountability, teamwork, resilience, time management, adaptability and decision-making.

Working Conditions

Office-based with hybrid operational support where applicable; rotational shifts and after-hours standby, including weekends and public holidays. Additional hours may be required during medical emergencies or operational peaks; occasional travel may be required.