Talent Pool: Clinical Governance Researcher

1 week ago

Sandton, Gauteng, South Africa Momentum Group Limited Full time R1 200 000 - R2 500 000 per year
Introduction

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.



Role Purpose

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



Duties & Responsibilities

PROCESS

  • 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.

CLIENT

  • Investigate client queries within the agreed service level and ensure that client receives timeous feedback.
  • Escalate client queries to the relevant department or stakeholder.
  • Provide regular reports on delivery of services against agreed service level agreements and in terms of overall customer targets.
  • Provide authoritative, expertise and advice to clients and stakeholders.
  • Build and maintain relationships with clients and internal and external stakeholders.
  • Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed.
  • Make recommendations to improve client service and fair treatment of clients within area of responsibility.
  • Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.

PEOPLE

  • Develop and maintain productive and collaborative working relationships with peers and stakeholders.
  • Positively influence and participate in change initiatives.
  • Continuously develop own expertise in terms of professional, industry and legislation knowledge.
  • Contribute to continuous innovation through the development, sharing and implementation of new ideas.
  • Take ownership for driving career development.

FINANCE

  • Contribute to the financial planning process within area.
  • Identify opportunities to enhance cost effectiveness and increase operational efficiency.
  • Manage financial and other company resources under your control with due respect.
  • Provide input into the risk identification processes and communicate recommendations in the appropriate forum.


Requirements
  • Matric (Essential)
  • Nursing qualification (Essential)
  • Healthcare accredited course (Desirable)
  • Minimum of 5 years Clinical experience
  • Registered with the SANC
  • 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
  • Good Written and oral communication skills


Competencies
  • Examining Information
  • Providing Insights
  • Taking Action
  • Inviting Feedback
  • Making Decisions
  • Team Working
  • Documenting Facts
  • Managing Tasks

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