Clinical Governance Researcher

2 weeks ago

Cape Town, Western Cape, South Africa Health Solutions Full time

Introduction

  • Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
    Role Purpose
  • Ensure that stakeholders are given the correct information within the Clinical Governance function

Requirements:

  • Matric
  • Nursing Qualification (Enrolled / Registered nurse)
  • Minimum of 5 years Clinical experience
  • Registered with the SANC
  • Minimum 3 years medical aid industry knowledge
  • Pharmacology knowledge
  • Computer literate and competent in Word / Excel
  • Knowledge of Oracle system (workflow, association of documents) an advantage
  • Good understanding of the medical scheme rules and regulations including
  • Knowledge of new medical technology
  • Good Written and oral communication skills

Duties & Responsibilities

  • Manage all complex clinical cases and requests for additional information from providers and members.
  • Research all data available regarding a request / appeal.
  • To be able to make a clinically appropriate decision pertaining to letter of motivation from providers.
  • Dealing with member and doctor queries.
  • Document decisions (update Workflow).
  • Telephonic resolution of queries where applicable.
  • Answering queries referred by Contact Centre, Pre-Authorisation, Scheme office and fund management, members and providers.
  • Producing stats and reports required by the schemes.

Competencies

  • Ability to converse confidently with members/ doctors/brokers.
  • Excellent communication skills (telephonic, verbal and written).
  • Research and investigational skills.
  • Professional attitude
  • Sound decision making ability
  • Integrity and confidentiality

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