Posted on: 17 August 2023
ID 880894

Clinical Governance Researcher

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 and 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
Occupation:
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