To work together with the Fund, Hospitals and all associated Service Providers to co-ordinate and monitor a Beneficiary's out of hospital benefits, Hospitalization and Post- Hospitalization health care needs in order to manage quality and costs in line with clinical guidelines and protocols and intervene when appropriate.
Requirements
- Matric
- Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife).
- Current registration with SANC, on application.
- ICU trained or experience would be advantageous.
- Minimum 3 years experience in managed health care industry.
- Minimum 2 years supervisory experience in a service environment.
- Previous experience or knowledge of the managed healthcare industry and financial services.
- Strong knowledge of PMB legislation, Clinical Coding (ICD 10, CPT & NHRPL), hospital and doctors billing guidelines is highly advantageous.
- Strong Oracle system knowledge is an advantage.
- Improve customer satisfaction by meeting all customer commitments in the delivery of the integrated value healthcare proposition of the schemes
- Supervising medicine risk, disease risk, prescribed minimum benefit and hospital risk programmes
- Performing regular quality assurance checks
- Communicating the policies and procedures of the company to the team, ensuring that they are implemented and adhered to duly
- Providing operational expertise
- Speed up the time to resolution and ensure consistency of service delivery
- Increase efficiency with tools that enable case managers/coaches to maintain and monitor cases and member journey experiences.
- Decrease number of manual processes and in-process time through workflow automation and consolidation of processes
- Improve service quality and customer satisfaction through the dissemination of knowledge and best practices - patient advocacy
- Accurate reporting to internal and external stakeholders
- Ensure that health risk management programmes meet cost containment criteria based on clinical protocols
- Adhere to the Service level agreements between the scheme and the administrator.
- Ensure that team functions optimally and in line with agreed upon key performance indicators
