To Qualify For This Position You Must Be
- Registered/Enrolled Nurse.
- Valid registration with SANC.
Skills And Competencies Required
- 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 i.e. 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/beneficiaries.
- Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols and funding guidelines.
- Loading of authorisations and the application of standard predictable within a telephone call.
- Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories.
- Clinical Risk Management to reduce the risks associated with hospital and other authorised services.
- Establish the presence of any co-morbid conditions from the caller or beneficiary if caller is not able to assist.
- 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 programs.
