Nurse Disease Management Coach

2 weeks ago

Johannesburg, 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 2023
- 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 2023

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 problem-solving
- 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 third-party 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 re-admissions
- 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 decision-making when required.
- Provide support in conducting year-end 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 ISO9001:2015.
- Maintain and enforce all clinical risk-related 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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