Role Purpose

• To ensure the implementation of best practices and optimal medical care for members through expert clinical guidance, collaboration with healthcare professionals, and continuous improvement initiatives.

Requirements

• Matric or National Senior Certificate
• A nursing degree (Bachelor of Nursing Science or equivalent) or National Diplomana in Nursing.
• Registration with the South African Nursing Council (SANC) for nursing professionals.
• 3 – 5 years of experience as a registered nurse practitioner or equivalent experience.
• 3 – 5 years of experience within the healthcare industry.
• 2 – 3 years of experience within the managed care environment and/or healthcare consulting industry would be advantageous.
• 3 years’ of work experience within theatre would be advantageous

Knowledge

• In-depth knowledge of evidence-based clinical guidelines, protocols, and best practices.
• Comprehensive knowledge of common medical conditions, diseases, and treatment modalities.
• Familiarity with the healthcare system and regulations in South Africa, including knowledge of relevant laws, policies, and regulatory bodies governing healthcare delivery, patient rights, and ethical standards.
• Understanding of quality improvement methodologies, patient safety principles, and tools for monitoring and improving healthcare outcomes.
• Knowledge of adverse event reporting, risk management, and quality assurance processes is important.
• Knowledge in utilising health information systems, electronic health records (EHRs), and other healthcare technologies
• Understanding of ethical principles and ethical decision-making in healthcare, including patient confidentiality, informed consent, and end-of-life care.
• Familiarity with research methodologies, critical appraisal of research studies, and the ability to apply evidence-based practice in clinical decision-making.
• Awareness and understanding of cultural diversity, sensitivity to cultural differences, and the ability to provide culturally competent care to patients from diverse backgrounds.
• Understanding how clinical guidelines and protocols intersect with scheme rules and regulations.
• Familiarity with the guidelines and regulations governing prescribed minimum benefits.

Duties & Responsibilities
PROCESS

• Meet the daily key performance indicator for proactive communication with members, ensuring timely assistance and effectively meeting their needs.
• Optimize bin management turn-around time, streamlining the process for prompt issue resolution and improving operational efficiency, in accordance with key performance indicator specifications.
• Implement policies and protocols related to scheme benefits to ensure consistent application and adherence, resulting in improved clarity and member satisfaction.
• Ensure appropriate control of benefits in and out of the hospital by closely monitoring utilisation, resulting in cost-effective care while maintaining quality outcomes.
•  Apply exclusions correctly and consistently based on policy guidelines and regulatory requirements, ensuring fairness and accuracy in benefit coverage determinations.

CLIENT

• Maintain quality customer service by promptly addressing members’ inquiries and concerns, resulting in enhanced member satisfaction and trust.
• Build and maintain positive relationships with relevant stakeholders (e.g., hospitals and providers), fostering effective collaboration and ensuring seamless coordination of care for members.

PEOPLE

• Appropriately refer cases to the case management team, ensuring members receive comprehensive care coordination, resulting in improved health outcomes and member satisfaction.
• Collaborate with the case management team, leveraging clinical expertise to support and enhance their decision-making process, leading to optimal care plans and member well-being.

FINANCE

• Monitor and manage healthcare utilisation and costs, optimising resource allocation and maintaining financial sustainability while ensuring high-quality care.
• Identify cost-saving opportunities and process improvements, contributing to improved financial efficiency and organisational effectiveness.

Competencies

• Examining Information
• Resolving Conflict
• Upholding Standards
• Exploring Possibilities
• Team Working
• Taking Action
• Directing People
• Following Procedures