Clinical Specialist - Sandton, South Africa - Discovery Ltd.
Description
Business Unit:
Discovery Health
Function:Clinical
Date:12-Apr-2023- Key Purpose:
Key Outputs:
- The successful applicant will be responsible for but not limited to the following job functions:
- Provide clinical support to the PMB and IH teams, MRT, exec office, benefit compliance review, the underwriting, and forensics area, as well as other business areas.
- Ensuring that related workflow pools TWT are met.
- Participating in key clinical forums internally and externally
- Daily Clinical Review
- Preparing of cases, case presentation, loading member remarks and clinical exceptions, arranging second opinions/external expert opinion and follow up.
- Communication of funding decisions to the relevant parties
- Keeping abreast with legislative and industry changes and how it affects your business unit.
- Keeping updated with the latest clinical thinking and attending relevant CPD events
- Identification of new trends in Medical Industry, as well as standard level of care, and engagement with relevant clinical stakeholders
- Constant interaction and relationship building with external health care providers.
- Maintenance of database of funding decisions made.
- Support to Junior Staff and other members of the team
- Knowledge of Claims, coding and assisting in getting payment resolutions
- Identify operational gaps and initiate improvement strategies.
- Review of clinical evidence on a casebycase basis
- Liaison with various business technical working groups (TWGs)
- Competencies:
- Learning on the Fly: Learns quickly when facing new problems; a relentless and versatile learner; open to change; analyzes both successes and failures for clues to improvement; experiments and will try anything to find solutions; enjoys the challenge of unfamiliar tasks; quickly grasps the essence and the underlying structure of anything
- Problem Solving:
- Priority Setting:
- Conflict Management:
- Interpersonal Savvy:
- Peer Relationships:
- Dealing with Paradox:
- Qualifications & Experience:
- The following requirements are essential:
- Matric
- Postgraduate clinical qualification: Registered Nurse, Biokineticist, Physiotherapist, Occupational Therapist
- Full and Current registration with relevant council
- Minimum of two years' experience in a private hospital or clinic
- Managed Health Care experience advantageous
Knowledge & Skills:
- Knowledge of Managed Care Environment advantageous
- Sound knowledge of Prescribed Minimum Benefits
- Excellent written and verbal communication skills in English.
- Knowledge of Discovery Health Medical Scheme and In-House products advantageous
- EMPLOYMENT EQUITY
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