Position Purpose:To facilitate the setting of quality standards, policies, and procedures (clinical and non-clinical) for area. Ensure adherence to audit requirements, reporting and planning through evaluation, and coaching internal resources.Experience:5 years' experience in the Managed Care environment in pre-authorisation call centre/ hospital case management or hospital claims. Working experience with a team of medical advisors will be an added advantage. QualificationsEnrolled or Registered Nurse Generic Output DetailsAccountabilitiesContinuous improvement:Review and write clinical rules and processesDevelop clinical policies, procedures and and maintain other business rules related to business unit, to ensure optimal automationSystematically monitor and review all policy changesDemonstrate independent decision making in the evaluation and feasibility of requests for system improvements and policies / processesInteract with team members at all levels of the business in decision makingLiaise with all other Service Network Providers and Medscheme Operational areas to successfully develop Standard Operating ProceduresDeliver approved, signed off and published Standard Operating ProceduresCreate and maintain clinical and non-clinical policies and proceduresImplement practical solutions that use the specialist and departmental systems and processesProvide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisationIdentify problems and develop and propose solutions to present to appropriate leader or stakeholdersEnsure day to day operational support required from area of specialisation is provided to enhance performanceCost containment:Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisationContinuously review cost / benefit and Return on Investment within area of specialisation Drive customer-centricity:Maintain a high level of impact on other departments to support improved deliveryContinually increase understanding of client and stakeholder needs, satisfaction and service deliveryKnowledge management:Set up and maintain document libraryCoach internal resources on new Standard Operating ProceduresEnsure that adequate knowledge regarding specialisation is shared as required and maintained within the research libraryProvide advice and / or training as requiredMaintain, develop and implement specialist knowledge within the day to day operations of the organisationMaintain expertise level:Be a member of related professional bodiesEnsure CPD (continual professional development) or similar accreditation requirementsare met annually to ensure maintained specialist accreditationNetwork key relationships:Engage with and provide support to the established network of internal and external expert resources and partnersSpecialist support to projects:Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when requiredConform to project management disciplines when participating in projectsRepresent department or project on appropriate committees related to area of specialisation Position Specific OutputsCommunication with third partiesApproval of all GEMS radiology cases, radiology experience would be advantageousReview and reassign cases to the correct email or UMS boxesCompile and maintain weekly statistics.Daily communication to Business unit Managers, Team leaders - MA availability / Late cover / TAT.Arrange and/or coordinate second opinionsObtain discounted quotesObtain clinical information by contacting Member/Providers.Review and refer escalations to Medical advisorsRefer to Medical advisors if MA clinical input is required.Review cases referred to Medical advisors within our scope of practice according to policies and Scheme rules. Support the Medical advisors and team with any administrative functions where required. Competency RequirementsAttribute:InfluenceEntrepreneurshipCredibilityOwnershipCollaborationKnowledge:Knowledge and understanding of scheme rulesand productsKnowledge of Quality Assurance methodologiesKnowledge of policies and proceduresSkill:Numerical AbilityData modelling and evaluationAttention to Accuracy and DetailKnowledge and application of relevant legislationRelevant systems knowledge and applicationProblem solving and decision making skillsComputer Technology SkillsTask ManagementExecutive Business Writing SkillsAdobe Creative SuiteCustomer FocusCommunication Skills
