Talent Pool: Non-Disclosure Researcher

To investigate members’ claims and medical history by reviewing clinical history and application forms for declared conditions/ treatments and review undisclosed information to inform their decision on the membership claim.

PROCESS

• Identify and investigate potential non-disclosure cases, validating them through comprehensive checks on disclosed information, including application forms and clinical history documents.
• Conduct thorough research on non-disclosure of pre-existing clinical conditions/treatment, ensuring accuracy and completeness by analysing clinical history forms received from providers.
• Facilitate clear communication by liaising with members, providers, and brokers to explain processes, requirements, and investigation progress, and promptly respond to queries with clinically appropriate responses.
• Document all interactions and decisions using workflow tools like Oracle/QUI, and prepare precise correspondence regarding non-disclosure exclusions and termination, adhering to organisational standards and processes.
• Conduct analysis of non-disclosure statistics, cross-referencing authorisation codes to identify cost-saving opportunities, and maintain scheme-specific spreadsheets with accurate and pertinent data.
• Prepare detailed monthly statistics and reports for board submission, ensuring precision, and collaborate closely with the Business Intelligence team to develop insightful executive summaries for comprehensive analysis.
• Provide feedback to members, brokers, and providers upon decision resolution.
• Handle escalations related to investigations, ensuring timely and effective resolution.
• Conduct trend analysis, collaborate with other departments, and enhance Quality Assurance tools to align with the business strategy and maintain high standards of behaviour and compliance.
• Compile, maintain, and organise reports systematically, ensuring accurate record-keeping.
• Enhance and align Quality Assurance tools to measure behaviour, ensuring strict adherence to legal compliance, confidentiality, and organisational standards as necessary.

CLIENT

• Provide authoritative, expertise and advice to clients and stakeholders.
• Build and maintain relationships with clients and internal and external stakeholders.
• Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed.
• Make recommendations to improve client service and fair treatment of clients within the area of responsibility.
• Participate and contribute to a culture that builds rewarding relationships, facilitates feedback, and provides exceptional client service.

PEOPLE

• Develop and maintain productive and collaborative working relationships with peers and stakeholders.
• Positively influence and manage change and offer specialist support where required.
• Continuously develop own expertise in terms of professional, industry, and legislation knowledge.
• Contribute to continuous innovation through the development, sharing, and implementation of new ideas and involvement of colleagues and staff.
• Take ownership of driving career development.

FINANCE

• Contribute to the financial planning process within the area or responsibility.
• Identify opportunities to enhance cost-effectiveness and increase operational efficiency.
• Manage financial and other company resources under your control with due respect.
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum.

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