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Member Care Clinical Consultant
3 months ago
Position
:
Member Care Clinical Consultant (Pre-authorisations)
Reporting to**:
Operations Manager: Contact Centre
Location:
Head Office - Lynnwood, Pretoria
Salary:
Market related CTC package that includes medical scheme and provident fund
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), 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
- 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 (case 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.
Salary:
R26, R36,000.00 per month
Ability to commute/relocate:
- Pretoria, Gauteng: Reliably commute or planning to relocate before starting work (required)
