Member Clinical Associate, Pretoria

2 weeks ago

Pretoria, Gauteng, South Africa iMedrecruit Full time
About the job Member Clinical Associate, Pretoria

Member Clinical Consultant (Pre-authorisations), Pretoria
Our client, focusing on a risk and clinical assessment offering, is requiring a Member Clinical Consultant.

Roles and Responsibilities (but not limited to):

  • 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.
  • Loading authorisations
  • 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 (case management) if comorbid conditions are present for intervention and followup.
  • Prepare and present cases for escalation to member management for discussion and resolution.
  • Provide member care and education to patients

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. ICD10s, 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), inrooms procedures and other healthcare services requiring preauthorisation
  • 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
  • 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

Qualifications:

  • Registered/ Enrolled Nurse
  • Valid registration with SANC

Hours:

Shift work between 7h00 and 19h00 (Monday to Sunday).

Required:

ASAP

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