Clinical Governance Researcher

2 days ago

Centurion, South Africa Health Solutions Full time

**Introduction**

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

**Role Purpose**

Ensure that stakeholders are given the correct information within the Clinical Governance function.

**Requirements**:

- Matric
- Minimum of 5 years Clinical experience or in operations clinical area
- Minimum 3 years medical aid industry knowledge
- Pharmacology knowledge
- Computer literate and competent in Word / Excel
- Knowledge of Oracle system (workflow, association of documents) an advantage
- Good understanding of the medical scheme rules and regulations including PMB
- Knowledge of new medical technology

**Duties & Responsibilities**
- Manage all complex clinical cases and requests for additional information from providers and members
- Research all data available regarding a request / appeal
- To be able to make a clinically appropriate decision pertaining to letter of motivation from providers
- Dealing with member and doctor queries
- Document decisions (update Workflow)
- Telephonic resolution of queries where applicable
- Answering queries referred by Contact Centre, Pre-Authorisation, Scheme office and fund management, members and providers.
- Producing stats and reports required by the schemes

**Competencies**
- Understands how the business operates, what the key issues and risks are that drives business success; and how they impact on the commercial viability of potential ventures and the profitability of the Group.
- Understands how the business operates, what the key issues and risks are that drives business success; and how they impact on the commercial viability of potential ventures and the profitability of the Group
- Actively leads change, does what is right for the business and drives continuous improvement through innovation.
- Creates and maintains an open, positive working environment by generating commitment, building trust, a shared sense of purpose, empowerment in others and encouraging them to contribute to the best of their ability.
- Creates and maintains an open, positive working environment by generating commitment, building trust, a shared sense of purpose, empowerment in others and encouraging them to contribute to the best of their ability.
- Persuades, convinces, influences and inspires others, both within MMI and externally to win support, loyalty and gain commitment to the purpose of MMH.
- Persuades, convinces, influences and inspires others, both within MMI and externally to win support, loyalty and gain commitment to the purpose of MMH.
- Is sensitive to individual and cultural differences and demonstrates humility and an openness to engage people from diverse backgrounds and cultures to the mutual benefit of all parties concerned.
- Is sensitive to individual and cultural differences and demonstrates humility and an openness to engage people from diverse backgrounds and cultures to the mutual benefit of all parties concerned.

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