Quality Assurance Consultant

**3 SIXTY **3Sixty Health has a great opportunity for a suitably qualified individual to fulfil
**HEALTH **the advertised position and join their team.
**BACKGROUND ** 3Sixty Health is a black owned and managed, reputable and a major player

in driving South African economy by investing in ‘’black excellence’’3Sixty
Health is 100% black owned and black managed administrator. It is accredited by the council for medical schemes to offer both administration and managed care services, allowing for a fully integrated, beneficiary
- centric approach. Our core competencies in administration include membership management, billing, claim adjudication and customer services.
It is a medical aid administrator of Sizwe Hosmed Medical Scheme.

**POSITIONS **Quality Assurance Consultant

**DIVISION **Managed Health Care

**DEPARTMENT **Admin Ops

Ensuring all calls handled by the consultants within our Hospital Utilization and Disease
Risk Management Programs and handled professionally according to the prescribed

**JOB PURPOSE **criteria. To identify interventions needed by the department to improve the quality of our services, Preauthorisation, Pharmacy and Disease Risk Management Programs.

**LOCATION **Houghton, Gauteng

**DUTIES AND RESPONSIBILITIES**
- Analyse all inbound calls handled in Pre Auth, Hospital Utilization, Pharmacy Services department, and all Disease management programs.
- Ensuring that internal processes and protocols are adhered to.
- Evaluate the accuracy of claims in line with the scheme rules and adherence to agreed rates with the providers as well as in terms of coding rules e.g., tariff codes and the NHRPL codes
- Ensure that clinical auditor uses the criteria for reducing a claim, and using the most appropriate savings Explanation Of Benefits (EOB)
- Analyse a specified sample of the interventions done by the Disease Risk and Hospital Pre-Auth/Case managers and Pharmacy departments for clinical appropriateness and appropriate discharge planning activities.
- Assist in preparing monthly operational quality assurance reports and quality trends
- Report on the status of quality levels of staff, systems, and production activities
- Evaluate quality events, incidents, queries, and complaints, providing a feedback for training purposes
- Communicate any critical compliance risk noted from the activities to Quality Assurance Manager
- Highlight all errors identified and provide feedback to relevant managers.
- Highlight recurring errors, address, and provide solutions working in conjunction with all the unit managers.
- Suggest interventions needed for quality improvements including training needs where necessary.
- Coaching for performance improvement
- Attend departmental meetings

**QUALIFICATIONS AND EXPERIENCE**
- Matric
- Preferably Registered or Enrolled nurse (with SANC) with at least 3 years Private Hospital/

Managed Care Experience, or QA industry experience in other fields
- Certificate in Total Quality Management (preferable)
- Excellent Keyboard and typing skills
- Good knowledge of Scheme Rules and Medical Scheme Act
- Systems/IT interest or knowledge an advantage
- Excellent communication skills
- verbal and written.

**CORE COMPETENCY SKILLS**
- Ability to work under pressure, and meet deadlines
- Analytical thinker
- Attention to detail, customer care training an advantage
- Ability to work as part of a team
- Ability to multitask
- Ability to communicate at all levels (both written and verbal)

**Job Type**: Permanent

Ability to commute/relocate:

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

Application Question(s):

- Are you Registered or Enrolled nurse (with SANC) with at least 3 years Private Hospital?

Do you have good knowledge of Scheme Rules and Medical Scheme Act?

**Education**:

- High School (matric) (required)

**Experience**:

- 3Private Hospital/ Managed Care: 3 years (required)

Application Deadline: 2023/04/25