This position requires the successful candidate to be able to make funding decisions for clinically complex cases as per scheme rules, in keeping with principles of evidence-based medicine while promoting cost effective and quality healthcare for our members and managing interactions with external clinical providers.
Key Outputs
The successful applicant will be responsible for but not limited to the following job functions:
- Provide clinical support to the PMB and IH teams, MRT, exec office, benefit compliance review, the underwriting, and forensics area, as well as other business areas.
- Ensuring that related workflow pools TWT are met.
- Participating in key clinical forums internally and externally
- Daily Clinical Review Preparing of cases, case presentation, loading member remarks and clinical exceptions, arranging second opinions/external expert opinion and follow up.
- Communication of funding decisions to the relevant parties
- Keeping abreast with legislative and industry changes and how it affects your business unit.
- Keeping updated with the latest clinical thinking and attending relevant CPD events
- Identification of new trends in Medical Industry, as well as standard level of care, and engagement with relevant clinical stakeholders
- Constant interaction and relationship building with external health care providers.
- Maintenance of database of funding decisions made.
- Support to Junior Staff and other members of the team
- Knowledge of Claims, coding and assisting in getting payment resolutions
- Identify operational gaps and initiate improvement strategies.
- Clear knowledge of evidence-based medicine and the application thereof
- Review of clinical evidence on a case-by-case basis
- Liaison with various business technical working groups (TWGs)
Learning on the Fly: Learns quickly when facing new problems; a relentless and versatile learner; open to change; analyzes both successes and failures for clues to improvement; experiments and will try anything to find solutions; enjoys the challenge of unfamiliar tasks; quickly grasps the essence and the underlying structure of anything.
Problem Solving: Uses rigorous logic and methods to solve difficult problems with effective solutions; probes all fruitful sources for answers; can see hidden problems; is excellent at honest analysis; looks beyond the obvious and doesn't stop at the first answers.
Priority Setting: Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.
Conflict Management: Steps up to conflicts, seeing them as opportunities; reads situations quickly; good at focused listening; can hammer out tough agreements and settle disputes equitably; can find common ground and get cooperation with minimum noise.
Interpersonal Savvy: Relates well to all kinds of peopleup, down, and sideways, inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can defuse even high-tension situations comfortably.
Peer Relationships: Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers.
Dealing with Paradox: Can act in ways that seem contradictory; is very flexible and adaptable when facing tough calls; can combine traits seeming opposite like being compassionately tough, stand up for self without trampling others, set strong but flexible standards; can act differently depending upon the situation; is seen as balanced despite the conflicting demands of the situation.
Qualifications & Experience
The following requirements are essential:
- Matric
- Post-graduate clinical qualification: Registered Nurse, Bio-kineticist, Physiotherapist, Occupational Therapist
- Full and Current registration with relevant council
- Minimum of two years experience in a private hospital or clinic
- Managed Health Care experience advantageous
- Knowledge of Managed Care Environment advantageous
- Sound knowledge of Prescribed Minimum Benefits
- Excellent written and verbal communication skills in English.
- Basic computer Literacy in Microsoft Office applications (must be proficient in Excel)
- Knowledge of Discovery Health Medical Scheme and In-House products advantageous
The Companys approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.
