Key Purpose :
The successful applicant will be responsible for but not limited to the following job functions:
Assessing the case in relation to the following:
Members clinical history
Members benefit structure
Clinical Information and coding supplied
Level of care provided
Appropriateness of the facility
Appropriateness of the treating doctor
Appropriateness of treatment
Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care
Discharge planning by providing the member with alternatives to receive treatment (This includes Hospital @ Home, Homecare etc.)
Effective and accurate communication to all stakeholders:
Case update to the provider
Funding decisions and benefit confirmation to the members
Request for additional information from the treating doctor or practice manager
Engaging with Patient Services Manager and hospital staff
Handling escalations from Providers and internal stakeholders
Preparing and presenting complex case to clinical review
Trend Analysis of inefficiencies and proposals to correct
Appropriate internal case referrals for clinical management
Operational Targets:
Attend to patients on daily report
Review all low acuity admission requests
Quality of processes
Education and Experience:
The following requirements are essential:
Matric
Must be a Registered Nurse
Valid SANC Registration
3 years Clinical experience in a private hospital setting (ICU, Trauma/Casualty, Medical/General ward preferable)
2 years Managed health care experience
Microsoft Office (Specifically Excel experience)
Valid Driver's License and own transport ( working hours are between 08:30 -17:00 & travel up to 50KM may be required)
Effective Communication Skills (Verbal & Written)
Telephone Etiquette
Active Listening Skills
The following requirements are advantageous:
1 - 2 years ICU experience
Knowledge of DH SOP's and Process experience (internal only)
Provider payment arrangements (internal Only)
Clinical coding knowledge of ICD-10 and/or CCSA