Minimum Education: Nursing Qualification (Nursing Diploma as a registered nurse)

Minimum Experience: 3 to 5 years (previous pre-authorisation, case management experience in a managed healthcare environment is essential)

Duties and Requirements includes but is not limited to the following:

Knowledgeable of the Medical Schemes Act and Government Gazette on tariffs
Conduct telephonic assessment, competency assessments and first line interviews during recruitment
Responsible for the training of all new staff recruits in the areas of clinical assessing/auditing, pre-authorisation and specialised case management
Providing detailed training feedback post probation
Responsible for identifying and meeting training needs of existing staff
Responsible for identifying and updating system and process enhancements throughout the department
Review and update training manuals, guidelines, standard operating procedures (SOPs) and cheat sheets
Maintain quality control for Clinical auditing staff and provide monthly feedback and stats to senior manager
Monitor workload to ensure SLAs are met
Involvement with any complex hospital/ associated account queries leading to resolution and reconciliation of the account
Assist with all HR issues ie: performance counselling, change management etc.
System testing:
- Responsible for testing any system programming changes that affect the department
- Identify staff members who display an aptitude for testing and develop their testing abilities
Data Mining:
- Involvement with the data mining process from a statistical point of view within the areas of trends, costs and disease management, amongst others
- Review of data for the Annual statutory return of the scheme to Council for Medical schemes