Co--ordinator: Member Care

2 weeks ago

Pretoria, South Africa H2R Africa Full time

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 e.g ICD10s, 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.
- Attend to incoming calls from healthcare service providers and members.
- Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols and funding.
- Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation
- Clinical Risk Management to reduce the risks associated with hospital and other authorised.
- Establish the presence of any co-morbid conditions from the caller or beneficiary if caller is not able to.
- 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.

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