New Business Clinical Underwriter

Job Description, We are seeking a skilled Clinical Underwriter to evaluate and adjudicate complex new business applications using advanced clinical expertise. This role is responsible for delivering accurate, fair, and compliant underwriting decisions in accordance with the Medical Schemes Act, Scheme Rules, and internal underwriting policies. The successful candidate will manage high-risk cases, providing critical risk mitigation to protect the scheme’s financial sustainability. This position plays a key role in balancing clinical insight with business objectives, ensuring sound decision-making that directly impacts cost management and long-term scheme viability.,

Requirements,

Qualifications

Essential: Grade 12

Desirable: Relevant clinical qualification (e.g. Nursing, Clinical Associate, or similar)

Experience Requirements

Essential: 3+ years’ experience in Medical Scheme Administration, with direct exposure to New Business underwriting.

Desirable: Experience using administration systems such as MIP and SOL (Medikredit).

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Duties and Responsibilities,

Advanced Underwriting Risk Assessment

• Assess complex applications involving medical conditions and risk factors.
• Interpret medical disclosures, clinical terminology and diagnostic indicators.
• Analyse medical reports and additional clinical documentation.
• Identify undisclosed or under-disclosed conditions.
• Apply underwriting decisions using both: Clinical judgement, Regulatory and policy frameworks

Clinical Evaluation & Risk Identification

• Evaluate the severity, impact and risk exposure of medical conditions.
• Determine appropriate: Exclusions, Waiting periods, Acceptance terms
• Ensure alignment between clinical findings and underwriting outcomes.

Complex Case Review & Decision Validation

• Handle escalated or high-risk cases requiring deeper analysis.
• Provide guidance on complex underwriting scenarios.
• Ensure decisions are accurate, defensible and audit-ready.

Underwriting Administration & System Processing

• Capture applications and clinical underwriting outcomes.
• Record detailed underwriting decisions on the system.
• Action underwriting letters and confirm correct implementation.

Quality Assurance & Risk Mitigation

• Perform enhanced quality checks on complex cases.
• Identify risks that could result in significant financial exposure.
• Ensure strict compliance with legislation and Scheme Rules.

Activation Decision Support

• Confirm activation only once all clinical underwriting requirements are satisfied.
• Ensure correct reflection of exclusions and conditions before activation.

Reporting, Governance & Compliance

• Maintain detailed records for audit and regulatory purposes.
• Report on complex case outcomes and risk exposure.
• Ensure compliance with Medical Schemes Act and underwriting governance.

Specialist & Multi-Skilled Support Function

• Provide technical underwriting support to Non-Clinical Underwriters and New Business teams.
• Assist with workload balancing during peak periods.
• Guide decision-making in borderline or complex cases.

Complexity & Risk Level (Differentiator)

• High complexity: Requires clinical interpretation and judgement
• Exposure to high-risk, high-cost member profiles
• Direct impact on scheme sustainability and claims cost management
• Errors may result in significant financial loss and regulatory risk