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Member Clinical Associate

1 month ago

Pretoria, South Africa iMedrecruit Full time

**Member Clinical Consultant (Pre-authorisations), Pretoria**
Our client, focusing on a risk and clinical assessment offering, is requiring a Member
Clinical Consultant.

**Roles and Responsibilities (but not limited to)**:

- Attend to incoming calls from healthcare service providers and members/ beneficiaries.
- Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols and funding guidelines.
- Loading authorisations
- Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories.
- Clinical Risk Management to reduce the risks associated with hospital and other authorised services.
- Establish the presence of any co-morbid conditions from the caller or beneficiary if caller is not able to assist.
- Refer to member management (case management) if co-morbid conditions are present for intervention and follow-up.
- Prepare and present cases for escalation to member management for discussion and resolution.
- Provide member care and education to patients

**Skills and Competencies Required**:

- Minimum 2-3 years’ experience in 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 of hospital admissions (including Length of Stay and Level of Care), in-rooms procedures and other healthcare services requiring pre-authorisation
- Excellent telephonic and written communication capability within a call centre environment _(will be tested) _
- Computer literate _(will be tested) _- MIP Application System experience will be advantageous
- Good organisational and task prioritisation skills
- Outstanding multitasking skills
- Proficiency in English - written and verbal _(an additional language will be _
- advantageous) _
- Ability to research and analyse information
- High degree of accuracy and attention to detail
- Compile and submit relevant reports in accordance with strict deadlines
- Results orientated
- Maintaining confidentiality of information

**Qualifications**:

- Registered/ Enrolled Nurse
- Valid registration with SANC

**Hours**:
Shift work between 7h00 and 19h00 (Monday to Sunday).

**Required**:
ASAP