Clinical Specialist X2

2 weeks ago

Durban, South Africa Health Solutions Full time

**Introduction**

Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables businesses and people from all walks of life to achieve their financial goals and life aspirations.

We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members. Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.

**Role Purpose**

Accountable for clinical risk management processes, operationalizing process improvements, interpreting requirements from various stakeholders and collaboratively constructing meaningful conceptual to implementation rules and data mapping requirements for BSS configuration and Business transformational efforts, ensuring that the business processes and system capabilities are aligned to service delivery.

**Requirements**:
**QUALIFICATIONS**
- Matric
- Qualification as a Registered Nurse and registered with SANC (Essential)
- Training or coaching qualification (Advantageous)

**EXPERIENCE**
- 3-5 years operational experience (Essential)
- 3-5 years of experience in Managed Health Care is essential (especially understanding the CMS requirements and standards associated with the Medical Schemes Act, Regulations and Guidelines and Accreditation Standards)
- Claims Assessing experience (Advantageous)

**ATTRIBUTES**
- Knowledge of the NHRPL (National Health reference Price List - previously known as BHF), SAMA tariffs, ICD10, CPT (CCSA) coding is advantageous
- Deep knowledge of the Medical Schemes Act and the relevant Regulations
- Sound communication skills (both Written & Verbal)
- Diversity and Inclusiveness
- Collaboration, Adaptability, Results driven
- Teamwork
- Proactive
- Ability to work under pressure
- Strong organisation skills
- Attention to detail and high level of accuracy
- Ability to multi-task

**Duties & Responsibilities**

**DEVELOP AN UNDERSTANDING OF INTERNAL ENVIRONMENT IN LINE WITH BUSINESS REQUIREMENTS**
- Internal Processes_

1. Engage business stakeholders regularly on key operational processes in regards to Products, Systems, Content and Processes that will improve business outputs
2. Review clinical and technical data and identify how better to structure the data collection requirements and processes. Analyse trends to develop rules set required to increase straight through processes.
3. Map data and implement more data collection requirements to enhance the data visualization outputs of value demonstration
4. Design content required for more skillful rule authoring requirements for operational and system processes.
5. Identify training needs of the greater business team and engage collaboratively to support business leaders to address the gaps
6. Conduct gap analysis and provide feedback to team members and managers throughout the process
7. Annual updating of department process documents and process library
9. Liaise with trainers to ensure that their training material is accurate and continuously updated
10. Deliver on service level agreements made with clients and internal and external stakeholders to ensure that client expectations are managed
11. Develop and maintain productive and collaborative working relationships with peers and stakeholders
12. Positively influence and participate in change initiatives
13. Continuously develop own expertise in terms of professional, industry and legislation knowledge

**ENABLE CLIENT CENTRICITY WITHIN AREA OF RESPONSIBILITY**
- Client Services_

1. Build and maintain relationships with clients and internal stakeholders
2. Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed
3. Make recommendations to improve client service and fair treatment of clients within area of responsibility
4. Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service
5. Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery
6. Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advise and after sales service
7. Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes

**SELF MANAGEMENT AND TEAMWORK**
- People_

1. Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations
3. Positively influence and manage change and offer specialist support where required
4. Contribute to contin

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