Clinical Underwriter

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

As an applicant, please verify the legitimacy of this job advert on our company career page.

The successful incumbent will be responsible for ensuring accurate and compliant underwriting decisions through thorough investigation, adherence to guidelines, analysis of underwriting criteria, and maintenance of quality and compliance standards.

• Bachelor’s degree or equivalent qualification in a relevant field such as healthcare administration, nursing, allied health sciences, or another medical-related discipline (essential).


• Underwriting certification (desirable).

Experience

• 2 - 3 years practical experience in Clinical Health Risk Management and/or equivalent relevant experience.


• Health underwriting and familiarity with non-disclosure processes, principles, and terminology.


• Financial/Insurance industry (desirable).

Professional Licensing Requirements

• Registration with the Health Professions Council of South Africa (HPCSA) or the South African Nursing Council (SANC) (essential).

Knowledge

• Clinical knowledge (e.g., understanding of anatomy and physiology to assess medical conditions, treatments, and risks).


• Knowledge of medical classification systems (e.g., familiarity with ICD-10 codes).


• Basic understanding of Prescribed Minimum Benefits (PMBs).


• Knowledge of regulations set by the Council for Medical Schemes (CMS) and the Medical Schemes Act.


• Basic understanding of managed care processes and how they relate to underwriting.


• Awareness of operational processes that are connected to underwriting, ensuring coordination and efficiency within the broader healthcare system.


• Proficiency in using computer systems, software, and databases relevant to underwriting tasks.

• Conduct thorough medical assessments and apply clinical knowledge in a professional manner, ensuring accuracy and precision.


• Provide expert advice and support in underwriting, non-disclosure, and claims for moderate and complex assessments, effectively mitigating organisational risk.


• Make precise non-disclosure decisions for beneficiaries and dependents who fail to disclose health conditions upon joining the medical aid, adhering to the Medical Scheme Act, underwriting policy, and established standards, protocols, and guidelines.


• Allocate condition-specific waiting periods following non-disclosure investigations.


• Investigate client queries within agreed service levels, delivering timely feedback to ensure utmost client satisfaction.


• Review claims and authorization history to identify any additional non-disclosed health conditions, enhancing accuracy in underwriting decisions.


• Develop and maintain productive relationships with peers and stakeholders, fostering collaboration and effective communication.


• Establish and uphold underwriting policies and guidelines, ensuring consistency, defensibility, and adherence to industry standards.


• Manage non-disclosure escalations within specified turnaround times, resolving issues promptly and efficiently.


• Efficiently plan, administer, and process beneficiaries' health information in alignment with performance objectives, ensuring data integrity and compliance.


• Collaborate with stakeholders in conducting underwriting and medical research in targeted areas, facilitating informed decision-making.

Client

• Establish and nurture relationships with clients, internal teams, and external stakeholders, fostering strong connections and mutual trust.


• Meet and exceed service level agreements applicable to clients and stakeholders, effectively managing and surpassing client expectations.


• Provide recommendations to enhance client service and ensure fair treatment within the realm of responsibility, promoting satisfaction and loyalty.


• Provide accurate and timely resolution of client queries, utilising feedback to drive process improvements and optimise client service.

People

• Build strong relationships, share specialised knowledge, and demonstrate effective leadership, fostering collaboration and positive engagement.


• Continuously develop industry expertise and relevant knowledge, applying acquired insights to drive excellence.


• Positively influence and manage change, offering support and guidance when required, fostering adaptability and resilience.


• Foster a culture of innovation by involving colleagues and staff in the development and implementation of new ideas, driving continuous improvement.


• Contribute to work-centric thinking, productivity, service delivery, and quality management, promoting a high-performance work environment.


• Take ownership of driving career development, proactively pursuing growth opportunities and self-improvement.

Finance

• Implement and provide input into governance processes, systems, and legislation in the specialised area, ensuring compliance and efficiency.


• Escalate unresolved policy and governance compliance issues for investigation and resolution, promoting accountability and risk mitigation.


• Contribute to risk identification processes and communicate recommendations in the appropriate forum, enabling proactive risk management and mitigation.