Specialist Clinical Quality Assurance

3 weeks ago

Johannesburg, South Africa Careforce Medical Recruitment Full time

Reporting to: Senior Specialist Clinical Management

Location: On-site at the Head Office, Pretoria

Purpose of the position:
To manage and implement the clinical quality assurance measures and quality improvement programs for the managed healthcare company. To ensure all clinical services and programs are implemented and executed to the highest standards of care and in accordance with the contracted service levels.

Qualifications:

- Registered Nurse
- Valid registration with SANC

Skills and Competencies Required:

- Minimum 2-3 years’ experience within a similar role within a managed healthcare or medical scheme environment
- Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e., ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols
- Thorough, well-grounded clinical knowledge of the pre-authorisation and case management of hospital admissions (including Length of Stay and Level of Care)
- Extensive clinical knowledge related to all aspects of patient management, including disease management protocols and CMS algorithms for the management of CDL conditions
- Knowledge of oncology and chronic renal care plans will be advantageous
- Solid understanding of value-based care
- Outcome focused with the ability to manage competing demands
- Excellent verbal and written communication skills
- Advanced computer skills with a demonstrated ability to analyse system workflows and process - MIP Application System experience will be advantageous
- Ability to research and analyse information, systems, and processes
- Ability to liaise with external (clinicians and healthcare facilities) and internal (colleagues across all service areas) parties
- Demonstrated ability to effectively deal with emotionally charged and stressful situations
- Self-motivator and the ability to work effectively in an independent environment
- Good organisational and task prioritisation skills
- Outstanding multitasking skills
- High degree of accuracy and attention to detail
- Compile and submit relevant reports in accordance with strict deadlines
- Results orientated
- Maintaining confidentiality of information

Summary of Responsibilities:

- Daily (routine) review of relevant workflows to timeously identify potential bottlenecks that will impact operations and quality outputs
- Perform randomised quality assurance reviews per clinical user on an on-going basis.
- Perform route cause analysis on enquiries received and implement mechanisms, processes, and system changes to improve clinical quality short coming
- Identification of clinical, policy, protocol, funding guideline and scheme rule shortcomings that require intervention and/ or change
- Plan and conduct internal quality audits and follow-up on corrective actions as needed.
- Compile and analyse audit reports to identify trends requiring quality improvement.
- Conduct quality awareness sessions with all employees.
- Keep senior management informed of any matters or developments pertaining to legislation that may impact quality outcomes.
- Drive quality improvement initiatives within the managed care company

**Salary**: R30,000.00 - R40,000.00 per month

Ability to commute/relocate:

- Johannesburg, Gauteng: Reliably commute or planning to relocate before starting work (required)

License/Certification:

- Nursing Council registration (preferred)

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