Talent Pool

Role Purpose The purpose of this role is to manage the quality and cost of clinical and medical care by liaising with members and providers. Requirements Registered or Enrolled Nurse or Counsellor – Essential A Registered Nurse with the South African Nursing Council (SANC) – Essential Health Coaching certification – Advantageous Experience Minimum of 5 years working experience within Managed Care – Essential 3 years clinical practice as a registered nurse in the clinical setting – Essential Training as a Primary Care Nurse Practitioner – Advantageous Experience in both HRM and DRM – Advantageous Experience as a home-based case nurse – Advantageous Experience in community health centre-based nursing care – Advantageous Experience as a registered nurse in a GP practice – Advantageous Knowledge Advanced Excel skills Knowledge of prescribed minimum benefits basic principles Knowledge of managed care principles Knowledge of protocols and treatment plans Knowledge of pathology analysis Knowledge of the CDL conditions and the ICD10 codes Knowledge of preventative health benefits to manage health risks Knowledge of clinical guidelines and policies Knowledge of acute and chronic diseases, prevention, causes, and treatment Knowledge of anatomy and physiology Duties and Responsibilities PROCESS Prioritise work in accordance with required intensity of patient management Daily planning and organisation in accordance with allocated member Accountability for daily workload and required interventions Interaction with Patient, GP and Specialist and other providers including home-based and convalescent nurses Manage quality and cost of clinical and medical care by liaising with members and providers and manage the reduction of recurring costly events and medicine spend Work with individual consumers (beneficiaries and providers) of the scheme to achieve better health outcomes while helping beneficiaries to understand their disease(s) or health status Reduce the downstream clinical and financial risk associated with the beneficiary Co‑ordinate the required interactions between the various providers and hospitalist Keep detailed records of patient interaction and follow‑ups done by updating system records Ensure the effective, accurate and timely completion of relevant documentation accompanying transactions Continued Medical Education task Manage cost of an in‑ or out‑patient episode by implementing appropriate policies and guidelines Arrange post‑hospital care where necessary Authorise appropriate and cost‑effective medical care and treatment Ensure the consistent and correct application of exclusions Adhere to policies and procedures and take corrective action where necessary Adhere to organisational best practice and legislative requirements Ensure accurate application of acute case management protocols CLIENT Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery Drive client service delivery goal achievement in line with predefined standards to ensure clients receive appropriate advice and after‑sales service Manage client query processes and ensure queries are tracked, accurately resolved and used to improve client service and business processes Provide regular reports on delivery of services against agreed service level agreements and overall client targets Provide authoritative, expertise and advice to clients and stakeholders Build and maintain relationships with clients and internal and external stakeholders Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments Deliver on service level agreements made with clients and internal and external stakeholders to ensure client expectations are managed Make recommendations to improve client service and fair treatment of clients within area of responsibility Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service PEOPLE Build strong relationships through providing specialist know‑how and leadership to others, expressing positive expectations Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation Positively influence and manage change and offer specialist support where required Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff Seniority level: Mid‑Senior level Employment type: Full‑time Job function: Health Care Provider #J-18808-Ljbffr