Hospital Benefit Specialist-Bloemfontein - Sandton
DISCOVERY LTD
Hospital Benefit Specialist-Bloemfontein Business Unit: Discovery Health Function: Clinical Date: 15 Feb 2024 About Discovery Discovery's core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society. About Discovery Care Discovery Care is a subsidiary for Discovery Health - made up of 8 distinct areas with segmented teams responsible for the processing of specialized claims, CIB queries and escalated clinical queries processes while our case management teams are responsible for reviewing clinical cases for each of the specialized areas. Our clinical services area is also responsible for all council disputes while our high touch team provide hands on services and escalated query resolution to sensitive cases. Key Purpose: Managing the risk relating to in hospital admissions, through the application of clinical and coding knowledge and aligning to protocols, legislation, standard operating procedures (SOP's), service level agreements (SLA's) and the member's benefit structure. The role will apply to working in various settings, predominantly casualty. It is anticipated that the risk purpose will also extend into the general ward and high care/ICU settings as needed. Coordinating the care of certain patients who are vulnerable to care gaps during transitions particularlyentry into hospital through to the emergency room, and discharge from hospital. The populations most vulnerable to gaps in care during transitions include clinically high risk patients; patients undergoing major surgical procedures; and patients with low socio-economic circumstances. Please note: The successful applicants will be based at a designated hospital within the applicable region. Key Outputs The successful applicant will be responsible for but not limited to the following job functions: Assessing the case in relation to the following: Members clinical history Members benefit structure Clinical Information and coding supplied Level of care provided Appropriateness of the facility Appropriateness of the treating doctor Appropriateness of treatment Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care Discharge planning by providing the member with alternatives to receive treatment (This includes Hospital Home, Homecare etc.) Effective and accurate communication to all stakeholders: Case update to the provider Funding decisions and benefit confirmation to the members Request for additional information from the treating doctor or practice manager Engaging with Patient Services Manager and hospital staff Handling escalations from Providers and internal stakeholders Preparing and presenting complex case to clinical review Trend Analysis of inefficiencies and proposals to correct Appropriate internal case referrals for clinical management Operational Targets: Attend to patients on daily report Review all low acuity admission requests Quality of processes Onsite perception survey Personal Attributes: Emotional Intelligence - Ability to understand, use, and manage emotions in positive ways to communicate effectively, empathise with others and defuse conflict. Composure - Is cool under pressure; does not become defensive or irritated when times are tough; is considered mature; can be counted on to hold things together during tough times; can handle stress; is not knocked off balance by the unexpected; doesn't show frustration when resisted or blocked; is a settling influence in a crisis. 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. Decision Quality - Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions. Integrity and Trust - Is widely trusted; is seen as a direct, truthful individual; can present the unvarnished truth in an appropriate and helpful manner; keeps confidences; admits mistakes; doesn't misrepresent him/herself for personal gain. Negotiating - Can negotiate skillfully in tough situations with both internal and external groups; can settle differences with minimum noise; can win concessions without damaging relationships; can be both direct and forceful as well as diplomatic; gains trust quickly of other parties to the negotiations; has a good sense of timing. Perseverance - Pursues everything with energy, drive, and a need to finish; seldom gives up before finishing, especially in the face of resistance or setbacks. 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. Education and Experience: The following requirements are essential: Matric Must be a Registered Nurse Valid SANC Registration 3 years Clinical experience in a private hospital setting (ICU, Trauma/Casualty, Medical/General ward preferable) 2 years Managed health care experience Microsoft Office (Specifically Excel experience) Valid Driver's License and own transport ( working hours are between 08:30 -17:00 & travel up to 50KM may be required) Effective Communication Skills (Verbal & Written) Telephone Etiquette Active Listening Skills The following requirements will be advantageous: 1 - 2 years ICU experience Knowledge of DH SOP's and Process experience (internal only) Provider payment arrangements (internal Only) Clinical coding knowledge of ICD-10 and/or CCSA EMPLOYMENT EQUITY The Company's 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.
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