Nurse Disease Management Coach

2 weeks ago


Johannesburg, Gauteng, South Africa MHR Full time

Job Advert Summary:


MHR is urgently looking for a
Registered Nurse with
Disease Management experience to work as a
Disease Management Coach. This is a
permanent opportunity at a well-known medical aid
in
Randburg in
Johannesburg.


You will be required to work
5 days from the client's office in Randburg.

  • Valid Registered Nurse SANC licence for 202
  • National Diploma in Nursing (General, Community Health, Midwifery, and Psychiatry)
  • At least 3 years experience in Healthcare and Disease Management
  • Disease Risk Management/Coaching experience is essential
  • Diabetes and cardiovascular experience essential (CDE trained or willing to undergo training)

Minimum Requirements:

  • 3 years experience in a Healthcare
  • 3 years experience in Disease Management
  • Disease Risk Management/Coaching experience is essential
  • Diabetes and cardiovascular experience essential (CDE trained or willing to undergo training)
  • National Diploma in Nursing (General, Community Health, Midwifery, and Psychiatry)
  • Valid Registered Nurse SANC licence for 202
3

KNOWLEDGE

  • Medical Knowledge
  • Clinical Risk management and risk management practices and principles
  • Relevant legislation and regulatory frameworks
  • Medical Aid Industry
  • Claims Assessing

SKILLS

  • Excellent Verbal and Written Communication
  • Project Management
  • Managed healthcare
  • Business Acumen

ATTRIBUTES

  • Resilient
  • Detail orientated
  • Client centred
  • Results orientated, quality focused and compliance driven
  • Analytical thinking and problemsolving
  • Judgement and decision making

Duties and Responsibilities:


Responsible for telephonically analysing, developing, and implementing multifaceted risk management interventions on chronic patient-specific cases, utilising clinical, disease and case management skills to prevent or reduce the scheme's medical exposure.


  • Contacting members and building positive relationships with members to achieve favourable outcomes.
  • Analyse and interpret reports, clinical results, and patient history information to provide an action plan per patient.
  • Engage with the thirdparty Managed Care Partners and Medical Providers to facilitate registration on the appropriate programs and authorisation of care baskets.
  • Ensure adherence to care plans by encouraging members to consult with their doctors regularly and have their regular special investigations.
  • Ensure adherence to scheme rules on all authorisations and clinical updates where applicable.
  • Communicate with members and service providers to address disease management matters.
  • Assist with health risk management monitoring and management of hospital readmissions
  • Compile and submit detailed reports to the scheme on costs and patient progress
  • Support the Clinical Manager and HOD on any projects related to risk management.
  • Meet the required daily targets and operational delivery within the Clinical Risk Division according to set Service Level Agreements (SLA's) and the Performance Contract.
  • Develop and maintain a general clinical understanding of Tariff coding, ICD, CPT, SAMA, RPL and National Pharmaceutical Product Interface (NAPPI) codes and how these affect clinical billing rules.
  • Assist with complaints, queries, and escalations.
  • Monitor outputs and results to inform process efficiencies to achieve targets.
  • Accountable for adhering to and managing error rates according to the QA policy within the division.
  • Develop and maintain adequate knowledge of data handling and ensure proper record keeping of related records.
  • Contribute to the targeted research into local and international clinical guidelines and funding policies.
  • Participate in clinical projects/studies and interdisciplinary meetings as required.
  • Assist with special requests on any clinical decisionmaking when required.
  • Provide support in conducting yearend testing and special projects when required.
  • Provide knowledge and expertise of prevailing legislation within the funding environment.
  • Assist in identifying and adhering to fraud controls, risk prevention principles, sound governance and compliance processes, and tools to identify and manage risks.
  • Support and provide evidence to all internal, external, and ISO audit requirements.
  • Maintain quality risk management standards in line with the requirements from ISO9001:201
  • Maintain and enforce all clinical riskrelated Service Level Agreements to minimise business risk and ensure business continuity.
  • Review and amend all related Standard Operating Procedures in consultation with the Supervisor: Clinical Risk to ensure business optimisation.
  • Adhere to all relevant laws, policies, and Standard Operating Procedures throughout the organisation.
  • Treat information and documentation as private and confidential, and only disclose to any parties according to the SOP's and relevant regulations.
  • Build and maintain effective internal and external stakeholder relationships for the purpos


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