Clinical Services Advisor

**OVERALL PURPOSE OF JOB**

Please note that all Clinical Services team members are required to participate in an on-call rota to handle out-of-hours emergency pre-certification requests. An on-call allowance is provided.

**KEY DUTIES & RESPONSIBILITIES**

Clinical Services:

- Review medical questionnaires and reports of applicants in order to provide clinical underwriting decisions
- Handle pre-certification of out-patient, day-patient and in-patient treatments by co-ordinating treatment needs with the benefits offered in the insurance plan.
- Actively participate in our on-call rota system with Clinical Services colleagues globally to ensure that members and providers are able to obtain the information and approvals necessary at all times.
- Liaise with doctors and providers to obtain necessary and accurate medical information within stipulated timeframe.
- Conduct proactive case management of large loss and complex claims with timely notification and approvals as per operating procedures.
- Provide medical reviews on the nature of medical conditions to support delivery of services and investigate claims for possible abuse, fraud or medical negligence.
- Work closely with Customer Service colleagues to handle all claims related customer queries and complaints. The Clinical Services team may also be required to answer Customer Service calls during peak business/leave periods in order to ensure consistent achievement of KPIs.
- Identify worrisome trends and suggest changes to plan terms and conditions, benefits and any relevant policies and practices.

Compliance and Security
- Take responsibility for establishing and maintaining up-to-date personal and team’s awareness of all legislative, regulatory and Company-specific rules, policies and procedures related to performance of the role. Ensure consistent compliance with legal, regulatory and Company standards in line with underwriter requirements.
- Work in conjunction with the Head of Legal and Compliance to ensure that our expansion projects comply with all regional legal/regulatory standards, and that any changes in laws or regulations are built into our project plans/operational processes.
- Pay particular attention to the Company’s Information and Data Security policies when accessing and using all Company systems which may provide access to sensitive information assets, and strive to maintain the highest possible standards of information protection at all times.
- Take individual responsibility for accessing only the systems, records and information required to perform the role. Treat all data contained within those systems in a manner consistent with the Company’s Information and Data Security policies, and in line with the confidentiality clauses provided within the employment contract.
- Ensure any regulatory requirements relevant to the individuals role are met, include certain qualifications and CPD.

**SKILLS KNOWLEDGE AND EXPERIENCE REQUIRED**
- Qualified medical practitioner (MMBS or similar) or equivalent work experience.
- Comprehensive experience in a similar role with either a regional or international insurance provider. Prior exposure to international medical insurance products is preferred.
- Excellent communication skills; able to confidently and sensitively handle both written and verbal correspondence with providers, brokers, members and colleagues.
- Previous medical claims handling experience is an advantage.
- Strong analytical skills with a proven track record of detail-consciousness and accuracy.
- Good presentation skills.
- Well versed with latest medical terminologies.

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