Coordinator: Member Care - Pretoria, South Africa - Careforce Recruitment

Careforce Recruitment

Verified Company

Pretoria, South Africa

1 week ago

Posted by:

Thabo Mthembu

beBee Recruiter

Description

Position:
Coordinator: Member Care (Pre-authorisations)

Reporting to:
Contact Centre Operational Manager

Location:
On-site at the Head Office, Pretoria

_You will be required to work shifts between 7h00 and 19h00 (Monday to Sunday) _

Qualifications:

Registered/ Enrolled Nurse
Valid registration with SANC

Skills and Competencies Required:

Minimum 23 years' experience in a similar role within a managed healthcare or medical scheme environment
Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10's, CPT4, NRPL, PMB conditions and clinical protocols
Thorough, wellgrounded clinical knowledge of the preauthorisation of hospital admissions

(including Length of Stay and Level of Care), in-rooms procedures and other healthcare services requiring pre-authorisation

Excellent telephonic and written communication capability within a call centre environment _(will be tested) _
Computer literate _(will be tested) _
MIP Application System experience will be advantageous
Customer service orientation
Ability to liaise with external parties clinicians and members and to make decisions
Demonstrated ability to effectively deal with emotionally charged and stressful situations
Selfmotivator and the ability to work effectively in an independent environment
Good organisational and task prioritisation skills
Outstanding multitasking skills
Proficiency in English written and verbal _(an additional language will be advantageous) _
Ability to research and analyse information
High degree of accuracy and attention to detail
Compile and submit relevant reports in accordance with strict deadlines
Results orientated
Maintaining confidentiality of information

Summary of Responsibilities:

Attend to incoming calls from healthcare service providers and members/ beneficiaries
Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols, and funding guidelines
Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories
Clinical Risk Management to reduce the risks associated with hospital and other authorised services
Establish the presence of any comorbid conditions from the caller or beneficiary if caller is not able to assist
Refer to member management if comorbid conditions are present for intervention and followup
Attend to general enquiries
Prepare and present cases for escalation to member management for discussion and resolution
Provide member care and education to patients with and without chronic conditions who need to participate in any of the registered active disease management programs.

Ability to commute/relocate: