Hospital Benefit Specialist

**Business Unit**:Discovery Health

**Function**:Clinical

**Date**:26 Feb 2025

**About Discovery**

Discovery’s core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.

**About Discovery Care**

Discovery Care, a subsidiary of Discovery Health, comprises of several specialized clinical areas with segmented teams. The Chronic and PMB Management team handles the processing of Chronic and Prescribed Minimum Benefit requests and manages escalated clinical queries. The HIV/Oncology and In-Hospital Case Management teams review clinical cases specific to their areas of expertise. The High Touch team provides hands-on services and resolves escalated queries for sensitive cases. Additionally, the Hospital Benefit Specialists, as part of field force, are responsible for real-time risk management and the Care Coordination Services manages the Managed Care programs.

**Key Purpose**:
The successful applicant will be responsible for but not limited to the following job functions:
Assessing the case in relation to the following:

- Members clinical history
- Members benefit structure
- Clinical Information and coding supplied
- Level of care provided
- Appropriateness of the facility
- Appropriateness of the treating doctor
- Appropriateness of treatment
- Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care
- Effective and accurate communication to all stakeholders:

- Case update to the provider
- Funding decisions and benefit confirmation to the members
- Request for additional information from the treating doctor or practice manager
- Engaging with Patient Services Manager and hospital staff
- Handling escalations from Providers and internal stakeholders
- Preparing and presenting complex case to clinical review
- Trend Analysis of inefficiencies and proposals to correct
- Appropriate internal case referrals for clinical management
- Operational Targets:

- Attend to patients on daily report
- Review all low acuity admission requests
- Quality of processes

**Competencies**:
**Role Specific Behaviours**
- Ensures accountability.
- Action oriented
- Manages ambiguity.
- Business insight
- Collaborates
- Communicates effectively.
- Manages complexity.
- Manages conflict.
- Courage
- Customer focus
- Decision quality
- Cultivates innovation.
- Interpersonal savvy
- Builds networks.
- Nimble learning
- Organizational savvy
- Persuades
- Plans and aligns.
- Being resilient
- Resourcefulness
- Demonstrates self-awareness.
- Self-development
- Situational adaptability

**Education and Experience**:
The following requirements are essential:

- Matric
- Must be a Registered Nurse
- Valid SANC Registration
- 3 years Clinical experience in a private hospital setting (ICU, Trauma/Casualty, Medical/General ward preferable)
- 2 years Managed health care experience
- Microsoft Office (Specifically Excel experience)
- Valid Driver’s License and own transport ( working hours are between 08:30 -17:00 & travel up to 50KM may be required)
- Effective Communication Skills (Verbal & Written)
- Telephone Etiquette
- Active Listening Skills

The following requirements are advantageous:

- 1 - 2 years ICU experience
- Knowledge of DH SOP’s and Process experience (internal only)
- Provider payment arrangements (internal Only)
- Clinical coding knowledge of ICD-10 and/or CCSA

**Personal Attributes or Competency Profile**

**The Discovery Person**
- Values Driven
- Optimistic
- Learns on the Fly
- Resilient
- Instils Trust
- People Savvy
- Drives Results
- Problem Solver