Consultant Risk Management

1 day ago

Centurion, South Africa PPS Group Full time

**THE IDEAL CANDIDATE SHOULD HAVE**:

- Nursing qualification.
- Intensive Nursing Science/Theatre would be advantageous
- Operating Theatre or ICU experience
- Prosthesis preauthorization management experience

**KEY RESPONSIBILITIES INCLUDE**:

- Ensuring successful Pre-Authorisation, Case management, Prosthesis and Disease management within the Clinical Risk Department.
- Ensure adherence to Scheme Rules on all Hospital Authorisations, clinical updates, and Benefit communication.
- Effective handling of Internal/External Clinical Queries Communicate with members and service providers to address all Clinical related matters
- Assist with Health Risk Management Monitoring & Management of members. Analyse and interpret reports, clinical results, and patient history information to provide an action plan per patient.
- Refer appeals to the Medical Advisor to make a final decision
- Keeping up to date with the latest clinical data supplied by the suppliers, and interpreting, presenting and discussing this data with team members.
- Maintaining knowledge of new developments in legislation, anticipating potential negative and positive impacts on the business and adapting strategy accordingly.
- Create alternative treatment plans to ensure the most cost-effective treatment of cases
- Review the hospital authorisations where prosthesis will be used to update pending and rejected authorisations
- Actively negotiate discount on all prosthesis requests on behalf of the Scheme
- Advise service providers and members on cost effective use of prosthesis in accordance with the Scheme Rules
- Facilitate enquiries regarding prosthesis benefits and discount
- Provide training to clinical consultants on the use of devices and equipment
- Reviews requests for prosthesis for approval and communicate to members/providers
- Keep record of all negotiated discounts
- Create reports to the schemes on prosthesis
- Propose DSP agreement to the Schemes
- Propose benefit design changes to Schemes
- Liaise with prosthesis suppliers re product information, cost and trail information relating to their products.
- Maintain the Prosthesis Reference price list.
- Review new prosthesis related products and map them to the correct benefit.
- Compile & submit detailed reports to the Scheme on costs and savings.

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