Coordinator: Member Care

2 weeks ago


Pretoria, Gauteng, South Africa Careforce Recruitment Full time

Position:
Coordinator: Member Care (Pre-authorisations)

Reporting to:
Contact Centre Operational Manager

Location:
On-site at the Head Office, Pretoria

_You will be required to work shifts between 7h00 and 19h00 (Monday to Sunday) _

Qualifications:

  • Registered/ Enrolled Nurse
  • Valid registration with SANC

Skills and Competencies Required:

  • Minimum 23 years' experience in a similar role within a managed healthcare or medical scheme environment
  • Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10's, CPT4, NRPL, PMB conditions and clinical protocols
  • Thorough, wellgrounded clinical knowledge of the preauthorisation of hospital admissions
(including Length of Stay and Level of Care), in-rooms procedures and other healthcare services requiring pre-authorisation

  • Excellent telephonic and written communication capability within a call centre environment _(will be tested) _
  • Computer literate _(will be tested) _
  • MIP Application System experience will be advantageous
  • Customer service orientation
  • Ability to liaise with external parties clinicians and members and to make decisions
  • Demonstrated ability to effectively deal with emotionally charged and stressful situations
  • Selfmotivator and the ability to work effectively in an independent environment
  • Good organisational and task prioritisation skills
  • Outstanding multitasking skills
  • Proficiency in English written and verbal _(an additional language will be advantageous) _
  • Ability to research and analyse information
  • High degree of accuracy and attention to detail
  • Compile and submit relevant reports in accordance with strict deadlines
  • Results orientated
  • Maintaining confidentiality of information

Summary of Responsibilities:

  • Attend to incoming calls from healthcare service providers and members/ beneficiaries
  • Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols, and funding guidelines
  • Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories
  • Clinical Risk Management to reduce the risks associated with hospital and other authorised services
  • Establish the presence of any comorbid conditions from the caller or beneficiary if caller is not able to assist
  • Refer to member management if comorbid conditions are present for intervention and followup
  • Attend to general enquiries
  • Prepare and present cases for escalation to member management for discussion and resolution
  • Provide member care and education to patients with and without chronic conditions who need to participate in any of the registered active disease management programs.

Ability to commute/relocate:

  • Pretoria, Gauteng: Reliably commute or planning to relocate before starting work (required)
Application Deadline: 2023/04/30

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