Consultant Pretoria - Pretoria
The Ideal Crew
Responsibilities: ● 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 authorized services. ● Establish the presence of any co-morbid conditions from the caller or beneficiary if the caller is not able to assist. ● Refer to member management (case 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. Working hours: shifts between 7h00 and 19h00 (Monday to Sunday) Preferred candidate will reside in Pretoria, Centurion or Midrand Salary is a Market related (around R30k - R35k) CTC package that includes medical scheme and provident fund Requirements: ● Registered/ Enrolled Nurse ● Valid registration with SANC ● 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. ICD10's, 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 center 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 organizational and task prioritization skills ● Outstanding multitasking skills ● Proficiency in English – written and verbal (an additional language will be advantageous) ● Ability to research and analyze 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
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