Key Purpose :
Management of enrolled Oncology members by reviewing clinical appropriateness of treatment is prescribed. This involves the correct application of Clinical Entry Criteria, Protocols, SOP's and Clinical guidelines as well as explaining the benefit to the member and counselling the member.
Key Outputs:
The successful applicant will be responsible for but not limited to the following job functions:
Enroll Member on Oncology Program and ensure that the member meets all requirements to qualify for the benefit (i.e. Forensics, Underwriting categories)
Review treatment plans in line with the SAOC and Icon guidelines
Approve treatment in line with SAOC/Icon as well as Discovery Health protocol.
Decline treatment which is not in line with SAOC\ICON as well as internal Discovery Health protocol.
Refer complex cases to internal and external Medical Review teams and provide feedback to both members and Providers.
Communicate funding decisions to members, employers and brokers verbally or in writing.
Make comprehensive notes on treatment that was approved/declined and how the funding decision was made.
Mitigate risk by using clinical knowledge to identify risk and reporting it accordingly.
Provide support to members, CHO Service Agents, Doctors and Pharmacist.
Support to Doctors by coordinating treatment plans and sending them updated guidelines and information.
Meeting daily Operational targets.
Education and Experience:
The following requirements are essential:
Matric
Registered & Enrolled Nurse
Registered with SANC
2 years Clinical experience
Knowledge of Oncology Treatment Interventions
Microsoft Office
Effective communication skills (verbal & written)
Effective presentation skills
Telephone Etiquette
Active listening skills
The following requirements will be advantageous:
1-year experience as a Case Manager.
DH systems and products.