Position: Clinical Care Coordinator: Appeals and Disputes Team (ADT)

Location: Centurion, Gauteng

Position Purpose: To provide expert clinical assessment and decision making in relation to Ex gratia applications, regulatory (CMS) complaints, appeals, disputes and escalations.

Qualifications & Experience: Registered Nurse with medical diploma/degree and valid SANC registration (MANDATORY REQUIREMENT)

5 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration industry or similar.

Solid working experience with the following:

Appeals and Disputes Management

• Review and assess clinical appeals and disputes in line with scheme rules and clinical guidelines
• Analyse clinical documentation, treatment plans, and provider motivations
• Make evidence‑based recommendations on benefit funding and clinical appropriateness ...