Member Clinical Consultant

Our client, a managed care organisation in Pretoria is currently looking for a Member Care Clinical Consultant (Pre-authorisations).
- **You will be required to work shifts between 07h00 and 19h00 (Monday to Sunday).**_

**Reporting to**:Operations Manager: Contact Centre

**Location**:Head Office - Lynnwood, Pretoria (On-site)

**Salary**:Market related CTC package that includes medical scheme and provident fund

**Qualifications**:

- Registered Enrolled Nurse
- Valid registration with SANC

**Skills and Competencies Required**:

- 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.
- Customer service orientation
- Ability to liaise with external parties - clinicians and members - and to make decisions.
- 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
- 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

**Summary of Responsibilities**:

- 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.
- 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.
- Attend to general enquiries.
- Prepare and present cases for escalation to member management for discussion and resolution.
- Provide member care and education to patients with and without chronic conditions who need to participate in any of the registered active disease management programs.