A oportunidade
Conheça a função e prepare a sua candidatura.
| Primary Function |
| To apply clinical knowledge when assessing and interpreting requests related to but not limited to benefits that require authorization, in order to manage and reduce the clinical and financial risk of the product. |
| Outputs | |
| 1 | To reflect a strong sense of and respect for, confidentiality involving both clients and service providers clinical information. |
| 2 | To provide accurate information to customers in line with the insurance product benefits, rules, standard operating procedures and protocols. To translate when required, Portuguese into English. |
| 2 | To work in liaison with all other healthcare professionals in the continuum of care, providing timeous, accurate updates of authorisation requests. |
| 3 | To negotiate the level of care and length of stay in accordance with clinical appropriateness with hospitals, providers and places of care. |
| 4 | To monitor and evaluate treatment requirements in order to manage the risk of all patients. |
| 5 | To ensure on-going case management of high risk members, facilitating early discharge planning and post hospitalisation care. Including on-site visits to hospitals/clinics and service providers. |
| 6 | To ensure that client and interdepartmental service level agreements are maintained. |
| 7 | To identify cases that need to be referred to medical advisors for further clinical opinion in order to ensure appropriate treatment is provided. |
| 8 | To ensure accurate record keeping take place and to produce ad hoc reports upon request. |
| 9 | To ensure the timeous and effective facilitation of hospital/chronic medication pre-authorisation requests and inbound queries in order to provide resolution to meet the customers’ specific need. |
| 10 | Provide assistance with regard to in- country transfers and international evacuations when required. |
| CUSTOMERS / STAKEHOLDERS | |
| Front Office | Members |
| Member Care Team Cape Town | Doctors/Healthcare providers/Hospitals/Clinics/Pharmacies |
| Operations Team Cape Town | Employer Group Clients |
| Underwriting Team | |
DECISIONS
|
These are decisions that the staff member can make independently and without supervision. List the decisions the individual makes, contributes to or recommends. Decisions |
| Decisions regarding specific cases in line with member care principles, standard operating processes and product rules. |
| Time Horizon |
| Medium to long term |
| Knowledge | Level (Basic, Intermediate, Advanced) |
| Application of clinical protocols | Advanced |
| Medical insurance products | Basic |
| ICD10 and CPT coding | Intermediate |
| Medware systems | Intermediate |
| Process understanding | Intermediate |
| Skills | Level (Basic, Intermediate, Advanced) |
| Application of managed care principles | Basic |
| Telephone etiquette | Advanced |
| Interpersonal skills | Advanced |
| Analysis and problem solving skills | Intermediate |
| Medware system | Intermediate |
| Computer Skills – MS Office | Intermediate |
| Education | Essential / Advantageous |
| Senior school leaving certificate | Essential |
| Nursing Qualification and license to practice | Essential |
| Additional clinical qualifications | Advantageous |
| Type of Experience | Industry | Years | Essential / Advantageous |
| General Nursing | Health | 5 -10 | Essential |
| In Hospital Nursing | Private/State sector | 5 – 10 | Essential |
| Chronic conditions | Private/State sector | 3 – 5 | Advantageous |
BEHAVIOURAL COMPETENCIES
|
Behavioural success factors that are either pertinent to the role or carried out on a daily basis. These are the observable behaviours or personal attributes (actions, verbal or non-verbal cues) that you would see on a daily basis. Please bear in mind that the 8 chosen are the most important behavioural attributes – the others as listed may well be relevant too although not as essential to daily operations Behavioural Attributes |
|
| Achieving Personal Work Goals and Setbacks Ranking | |
| Adapting and Responding to Change | 8 |
| Adhering to Principles and Values | |
| Analysing | |
| Applying Expertise and Technology | 1 |
| Coping with Pressure and Setbacks | 7 |
| Creating and Innovating | |
| Deciding and initiating action | |
| Delivering Results and Meeting Customer Expectations | 5 |
| Entrepreneurial and Commercial Thinking | |
| Following Instructions and Procedures | 2 |
| Formulating Strategies and Concepts | |
| Leading and Supervising | |
| Learning and Researching | |
| Persuading and Influencing | |
| Planning & Organising | 3 |
| Presenting and Communicating Information | |
| Relating and Networking | |
| Working with People | 4 |
| Writing and Reporting | 6 |
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