Clinical Specialist

Closing Date 2024/05/31

Reference Number MMH230601-18

Job Title Clinical Specialist

Position Type Permanent

Role Family Medical

Cluster Health Solutions

Remote Opportunity Some of the time

Location - Country South Africa

Location - Province KwaZulu-Natal

Location - Town / City Durban

Introduction

Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables businesses 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. Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.

Role Purpose

Accountable for clinical risk management processes, operationalizing process improvements, interpreting requirements from various stakeholders and collaboratively constructing meaningful conceptual to implementation rules and data mapping requirements for BSS configuration and Business transformational efforts, ensuring that the business processes and system capabilities are aligned to service delivery.

Requirements

QUALIFICATIONS

Matric
Qualification as a Registered Nurse and registered with SANC (Essential)
Training or coaching qualification (Advantageous)

Experience

3-5 years operational experience (Essential)
3-5 years of experience in Managed Health Care is essential (especially understanding the CMS requirements and standards associated with the Medical Schemes Act, Regulations and Guidelines and Accreditation Standards)
Claims Assessing experience (Advantageous)
Experience in interpreting and applying scheme rules correctly

ATTRIBUTES

Knowledge of the NHRPL (National Health reference Price List previously known as BHF), SAMA tariffs, ICD10, CPT (CCSA) coding is advantageous
Deep knowledge of the Medical Schemes Act and the relevant Regulations
Sound communication skills (both Written & Verbal)
Computer literacy (Email, Word and Excel)
Diversity and Inclusiveness
Collaboration, Adaptability, Results driven
Teamwork
Proactive
Ability to work under pressure
Strong organisation skills
Attention to detail and high level of accuracy
Ability to multi-task

Duties & Responsibilities

DEVELOP AN UNDERSTANDING OF INTERNAL ENVIRONMENT IN LINE WITH BUSINESS REQUIREMENTS

Internal Processes

Engage business stakeholders regularly on key operational processes in regards to Products, Systems, Content and Processes that will improve business outputs
Review clinical and technical data and identify how better to structure the data collection requirements and processes. Analyse trends to develop rules set required to increase straight through processes.
Map data and implement more data collection requirements to enhance the data visualization outputs of value demonstration
Design content required for more skillful rule authoring requirements for operational and system processes.
Identify training needs of the greater business team and engage collaboratively to support business leaders to address the gaps
Conduct gap analysis and provide feedback to team members and managers throughout the process
Annual updating of department process documents and process library
Responsible to provide input to update training material that will help employees understand the subject matter more effectively and efficiently
Liaise with trainers to ensure that their training material is accurate and continuously updated
Deliver on service level agreements made with clients and internal and external stakeholders to ensure that client expectations are managed
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

ENABLE CLIENT CENTRICITY WITHIN AREA OF RESPONSIBILITY

Client Services

Build and maintain relationships with clients and internal stakeholders
Deliver on service level agreements applicable to 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
Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery
Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advise and after sales service
Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes

SELF MANAGEMENT AND TEAMWORK

People

Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations
Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation
Positively influence and manage change and offer specialist support where required
Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff
Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management
Take ownership for driving career development

CONTRIBUTE TO FINANCIAL CONTROLS AND PLANNING

Finance

Contribute to the development of area specific budgets to minimize expenditure, in alignment with operational plans
Identify solutions to enhance cost effectiveness and increase operational efficiency
Implement and provide input into governance processes, systems and legislation within area of specialisation
Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes
Provide input into the risk identification processes development and communicate recommendations in the appropriate forum

Competencies