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Clinical Advisor

To provide professional clinical and network management support to colleagues and customers throughout the Middle East and Africa region including input on clinical underwriting, medical advice for complex or high value claims and identifying/reporting any worrisome clinical trends. Liaise with members, healthcare providers and other third parties to pre-certify treatment (both routine and emergency), apply appropriate cost containment measures, and co-ordinate local and regional provider direct settlement networks.

Clinical Services:

  • Review individual and group member applications referred internally by our  Policy Administration, Sales or Underwriting teams
  • 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.
  • Apply prudent cost management measures by co-ordinating the provision of only medically necessary and appropriate health services.
  • 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.
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