Specialist Clinical Quality Assurance

2 weeks ago

Pretoria, South Africa H2R Africa Full time

Minimum 2-3 years experience within 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 e., ICD10s, CPT4, NRPL, PMB conditions and clinical protocols
- Thorough, well-grounded clinical knowledge of the pre-authorisation and case management of hospital admissions (including Length of Stay and Level of Care)
- Extensive clinical knowledge related to all aspects of patient management, including disease management protocols and CMS algorithms for the management of CDL
- Knowledge of oncology and chronic renal care plans will be advantageous
- Solid understanding of value-based care
- Outcome focused with the ability to manage competing demands
- Excellent verbal and written communication skills
- Advanced computer skills with a demonstrated ability to analyse system workflows and process - MIP Application System experience will be advantageous
- Ability to research and analyse information, systems and processes
- Ability to liaise with external (clinicians and healthcare facilities) and internal (colleagues across all service areas) parties
- 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
- High degree of accuracy and attention to detail
- Compile and submit relevant reports in accordance with strict deadlines
- Results orientated
- Maintaining confidentiality of information

DUTIES
- Daily (routine) review of relevant workflows to timeously identify potential bottlenecks that will impact operations and quality
- Perform randomised quality assurance reviews per clinical user on an on-going
- Perform route cause analysis on enquiries received and implement mechanisms, processes and system changes to improve clinical quality short
- Identification of clinical, policy, protocol, funding guideline and scheme rule shortcomings that require intervention and/ or
- Plan and conduct internal quality audits and follow-up on corrective actions as
- Compile and analyse audit reports to identify trends requiring quality improvement.
- Conduct quality awareness sessions with all
- Keep senior management informed of any matters or developments pertaining to legislation that may impact quality outcomes.
- Drive quality improvement initiatives within the managed care

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