Aleecia Loreal Naidoo

Extensive experience in Provider Relations - tariff and benefit structure negotiations, Provider engagements, enrolments and managements , SLA agreements.Member high level complaints resolution, claims query, compliancy and benefits structure within the Managed Care Organisation. I am high organised, efficient and proactive who is passionate and knowledgeable. I deliver high quality work consistently while meeting deadlines while professionalism and confidentiality with strict adherence to internal rules and process ,and the companies code of conduct. I obtained a clinical background and business acumen and a niche for IT systems, currently completing my MBA in International Healthcare Management. 

General Manager/ EcoMedical

Johannesburg

September 2022 - December 2022

Contracting Hospital Groups and Service Providers both Locally and Internationally. Developing SOPs for the business unit,
Workflow Design.
Marketing and design material for the product offering.

Medical reviewing and case analysis.
Referral to Clinicians for healthcare support and treatment. Presentations and product training.
Data and Risk analysis and Reporting to Board Members.

Clinical Governance Manager/ Improved Clinical Pathway Services

Johannesburg
July 2016 - August 2022

Staff and Operations Management
Internal and External Customer Engagements.
Development of IT infrastructure for workflow and report.
Development of Marketing materials, product developments, training and engagements.
SOPs development and clinical pathways.
KPI management for internal and external stakeholders
Reporting to external stakeholders and board members.
Budgeting, forecasting planning.
New business and Key Accounts Management.
High level escalations and investigations.
Data analysis and Market trends.
Tariff negotiations and annual increases for product portfolio. Governance reporting and presentations to external stakeholders.

Medical Claims Examiner/ Rand Mutual Assurance

Johannesburg

January 2015 - July 2016

Staff management and Training. Development of SOPs and training Materials.

Medical Management of claims aligned to treatment protocols and COIDA limits and generate Authorisation of treatment plans. Manage costs associated with the treatment authorization and claims Estimates.
Review and update ICD 10 codes based on First/Progress/Final Medical Reports/Investigation Results.

Review and update claims close to exceeding their Maximum Medical Improvement (MMI).
Case manage claims with estimated PD of 10% and above to ensure correct liability decisions are made.

Manage, review and adjudicate all claims related to occupational diseases. Referral of complex cases to the medical department for opinion and action accordingly..
Contribute and make input on claims complaints.

Disease Management Counsellor/ Universal Healthcare

Sunninghill

May 2013 - December 2014

Attend incoming phone calls from new enrolees on the Disease management Programme. Verify eligibility of beneficiary on medical scheme or health plan according to beneficiary data files.
Obtain supporting diagnostic information and confirm eligibility.

Capture on a disease management database relevant information about the beneficiaries chronic illnesses.
Ensure that service level agreements for clients are consistently met with regards to call answer service level and Disease management contacts.

HIV/AIDS and Chronic Disease Management
Phone the beneficiary according to a specified schedule and discuss their chronic conditions with the beneficiary.
Maintain confidentiality about the patient. Keep all information disclosed to the counselor confidential.
Explain the benefits of the Disease Management Programme to the beneficiary and the role of the Disease Management Programme.
Identify areas of the condition where the beneficiary requires education and support regarding their chronic diseases.
Provide education about the triggers and complications of their chronic diseases.
Provide education about the nature of the chronic illness (es), triggers that might aggravate their condition and lifestyle changes.
Ensure that the beneficiary understands how to take their medicines and the need to remain adherent to their treatment.
Educate the beneficiary about the management of their condition in an emergency.
Obtain regular relevant pathology results from the beneficiary and update them on the Disease Management Programme.
Set achievable goals and targets for the beneficiary to achieve i.e. lose a specified number of kilograms in a defined time period, reduce the cholesterol by a certain percentage etc.
Provide relevant dietary and lifestyle advice. All advice is required to be correct and appropriate to the condition.
Advise the beneficiary regarding standard cover for their conditions.
Obtain and follow up on pathology reports every 4-6 months.

Arrange and perform future follow up to counsel the beneficiary.
Fax or email the treatment prescription and/or application form to the relevant department. Arrange for relevant educational material to be mailed to the beneficiary.

Perform Voluntary Counseling and testing.
Health Check /VCT Days
If required, on a rotational basis, visit client business sites to perform VCT testing, TB Questionnaire, Blood pressure measurements, cholesterol and glucose testing.
Test, screen, advice and counsel appropriately.

Oncology Case Manager/ Medscheme Health Risk Solutions

Roodepoort
December 2012 - May 2013

Plans, develops, assesses, and evaluates care provided to members. Develops and maintains case management policies and procedures.

Coordinates, directs, and performs concurrent and retrospective reviews, and monitors level and quality of care.
Ensuring successful & smooth Pre-Authorisation and case management process telephonically and on email.

Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning.
Consults with Medical Advisor and external Physicians, health care providers regarding continued care/treatment or hospitalisation.

Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
Develops and collects data, and trends utilization of health care resources. Effectively apply all aspects of the nursing process within a collaborative interdisciplinary team.

Accurately documents the completion of procedures and the patient's responses. Demonstration of knowledge and skills necessary to provide care appropriate to the

needs of patients served in the assigned area of practice.
Accurately verify and validate providers' orders.
Safely implement all treatments/procedures and accurately.
Document the completion of treatments/procedures along with the patient's response. Ensure adherence to Scheme Rules.

Effective handling of Internal/External Clinical Queries. Communicate with patients and service providers in order to oncology treatment requests.
Assist with Health Risk Management Monitoring & Management. Carrying out Clinical coding in accordance with requirements and guidelines.

Compile and submit detailed reports when required.

HIV Case Manager/ Discovery Health

Sandton

August 2010 - December 2012

Enroll member on HIV Programmed and ensure that the member meets all requirements to qualify for the benefit (i.e. Forensics, Underwriting categories). Support and educate the members in relation to the following:
Knowing and understanding the disease

Accepting the condition/diagnosis
Treatment regimes and their prescribed medication
Terminology related to the disease and related pathology
Nutrition
Review scripts and pathology from a central work pool to ensure that the member receives medication and continuous treatment.
Facilitating medication delivery through the DSP.
Drug Utilization Review (DUR).
Applying internal disease management processes: monitoring compliance to testing doctor visits and medication.
Telephonic support to members, Chronic HIV & Oncology Service Agents, Doctors and Pharmacists.
Support to Doctors by co-coordinating treatment plans and sending them updated guidelines and information.

Clinical Auditor/ Medscheme Health RIsk Solutions

Roodepoort

April 2009 - July 2010

Ensuring hospital claims are audited timeously and accurately as per our service level agreement, focusing on customer centricity and the quality of service rendered to the member within the scheme's benefit design and the different hospital contracts. Auditing of doctors’ accounts, applying industry rules and guidelines as set out in the relevant Billing and tariff Manuals.

Review specific hospital claims for clinically appropriateness, treatment received, over usage of equipment / materials and consistency with billing rules.
Apply and comply with relevant scheme rules, regulations, standards, clinical policies, protocols, and procedures.

Liaise with the medical advisor if necessary.
Review and maintain clinical auditing rules annually.
Review hospital network billing guidelines annually and feedback to the business
To identify hospital trends and claiming patterns with the objective of changing provider behaviour and giving continuous feedback to the business.
To update knowledge and skills to deliver a cost-effective and professional service. Clinical support to the provider network team and discussing identified trends.
Attend quarterly clinical operational meetings and feedback regarding trends and application of billing guidelines.
Ensure clinical auditing work and volumes is timeous and within set service level agreement
Assist with authorisation-claim matching queries
Ensure accurate savings is recorded according to paid codes and reason codes. Measuring of individual error rate to ensure no costs incurred due to assessing errors made
Deliver a cost-effective Managed Healthcare service
Liaise with the different departments to receive relevant clinical, operational information. Use of appropriate personal protective equipment and safety systems
Excellent written and verbal communication and documentation skills.

Prospective Reviewer/ Medscheme Hospital Benefit

Management

Roodepoort

January 2008 - March 2009

Delivering cost-effective managed healthcare services to accomplish member satisfaction and to deliver affordable managed healthcare services
Client Relations, To assist the client by approving appropriate funding.
To deliver an effective call centre service in order to achieve member satisfaction. Risk Management ,To reduce the risk associated with hospital and authorized cases Telephone Etiquette , Answering telephone calls in a way that achieves member satisfaction.

Risk Management ,To reduce the risk associated with hospital and authorized cases Verifying prosthesis limits , To contain costs for both members and fund.

On-going training and development, To update knowledge and skills in order to deliver a cost-effective and professional service.
The actual benefit expenditure per beneficiary per month for hospitalization should be less than the budget benefit expenditure . Pre-authorization should be granted within the option benefits, Scheme and clinical protocols

Effective Customer Service delivery.To deliver an effective call centre service in order to achieve member satisfaction.
Delivering a cost-effective Managed Healthcare service within the average length of hospital stay per beneficiary.

Delivering a cost-effective Managed Healthcare service. To deliver affordable Managed Healthcare services.

File Assessor/ Netcare Parklands Hospital

Durban

March 2007 - November 2007

Verify the presence of a completed checklist on file. Effective delivery of quality customer care.

Supply proof of completed bill audit reports with additional copies placed in patient files.
Compile and maintain a Bill Audit file containing copies of the Edit accommodation reports, late charges and bill audit reports (per file) – all signed by Case Manager. Effective auditing of patient documentation.

Develop and maintain sound relationships with internal customers to achieve co-operation & compliance with audit processes.
Verify carrier code detail to correspond with patient medical aid card
Verify patient details on SAPS.

Evaluate data accuracy to identify deviations and make recommendations for corrective action and implement and monitor same.
Audit pre-set number of files according to Netcare standards, in order to achieve monthly target.

Verify presence of a copies of patient ID and medical aid on file.
Analyse data trends relating to rejections, short payments and Edit accommodations

Enrolled Nurse/ Netcare St. Augustines Hospital

Durban

June 2005 - February 2007

Assisting the Ward in the pre-screening, treatment and care of patients.
Assist Treatment Room in the prioritizing of medical emergencies. Actively maintain stock management processes.
Participate in monthly stock cycle counts.
Maintain emergency trolley in accordance with company policies and procedures. When scheduled to work, act as the responsible person after hours to ensure

smooth operations and escalate to the Sister in charge as and when required.

High School/ Avonford Secondary School Durban
January 2000 - December 2003
Exemption Pass

Nursing/ Nursing and Primary Healthcare College Durban
January 2004 - November 2006
Graduated with Distinction

MBA International Healthcare Management/ University of Cumbria

February 2022

Current Studies