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Coordinator: Member Care

4 months ago

Pretoria, South Africa Careforce Recruitment Full time

Position: Coordinator: Member Care (Pre-authorisations)
Reporting to: Contact Centre Operational Manager
Location: On-site at the Head Office, Pretoria
- **You will be required to work shifts between 7h00 and 19h00 (Monday to **_
- **Sunday)**_

**Qualifications**:

- Registered/ Enrolled Nurse
- Valid registration with SANC

**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
- 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 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.

Should you be interested in this position, and you meet the requirements, please send your CV, copies of SANC Registration, Certificates and Payslip.

Ability to commute/relocate:

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

Application Deadline: 2023/08/25