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Medical Benefits Coordinator

3 weeks ago

Nelspruit, Mpumalanga, South Africa The Talent Room Full time
Job Description

We are seeking a highly skilled Medical Benefits Coordinator to join our team at The Talent Room. As a Clinical Case Manager, you will play a critical role in ensuring optimal patient care and efficient resource utilization.

Key Responsibilities:
  • Pre-Authorizations
    • Evaluate and process requests for pre-authorizations for medical procedures and treatments.
    • Ensure all necessary information is gathered to make informed authorization decisions.
    • Communicate authorization decisions to healthcare providers and members promptly.
  • Case Management
    • Monitor and manage individual patient cases to ensure appropriate care and efficient use of resources.
    • Coordinate with healthcare providers to develop and implement care plans.
    • Follow up on patient progress and adjust care plans as needed.
  • Negotiation of Tariffs
    • Negotiate tariffs and fees with healthcare providers to ensure cost-effective care for members.
    • Ensure that negotiated tariffs comply with organizational policies and regulatory requirements.
    • Maintain accurate records of tariff agreements and monitor adherence to agreed terms.
  • Risk Management
    • Identify potential risks associated with patient care and preauthorization processes.
    • Develop and implement strategies to mitigate identified risks.
    • Monitor the effectiveness of risk management strategies and make adjustments as needed.
  • Confidentiality and Security
    • Maintain the highest level of confidentiality and security when handling sensitive personal/medical information in accordance with organizational policies and POPI Act.
    • Handle personal and medical information securely. All information coming into the organization should only be shared with authorized personnel and used for legitimate business purposes.
    • Cooperate fully during compliance audits to ensure adherence to the POPI Act, especially regarding the processing of health-related information.
Requirements:
  • Matric with mathematics
  • Diploma in business, risk or clinical nursing advantageous
  • Knowledge of Anatomy and Physiology advantageous.
  • Previous experience in case management, pre-authorizations, or a similar role strongly
  • Strong negotiation and communication skills.
  • Ability to manage multiple tasks and work under pressure.
  • Knowledge of healthcare regulations and compliance requirements strongly
  • Knowledge of different COID and Medical Aid rules and managed health care policies.
  • Proficiency in using case management software, ICD10codes and procedure codes strongly