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.
Qualifications:
Enrolled or Registered Nurse
Accountabilities:
Continuous improvement:
Review and write clinical rules and processes
Develop clinical policies, procedures and maintain other business rules related to business unit, to ensure optimal automation
Systematically monitor and review all policy changes
Demonstrate independent decision making in the evaluation and feasibility of requests for system improvements and policies / processes
Interact with team members at all levels of the business in decision making
Liaise with all other Service Network Providers and Medscheme Operational areas to successfully develop Standard Operating Procedures
Deliver approved, signed off and published Standard Operating Procedures
Create and maintain clinical and non-clinical policies and procedures
Implement practical solutions that use the specialist and departmental systems and processes
Provide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisation
Identify problems and develop and propose solutions to present to appropriate leader or stakeholders
Ensure day to day operational support required from area of specialisation is provided to enhance performance
Cost containment:
Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisation
Continuously 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 delivery
Continually increase understanding of client and stakeholder needs, satisfaction and service delivery
Knowledge management:
Set up and maintain document library
Coach internal resources on new Standard Operating Procedures
Ensure that adequate knowledge regarding specialisation is shared as required and maintained within the research library
Provide advice and / or training as required
Maintain, develop and implement specialist knowledge within the day to day operations of the organisation
Maintain expertise level:
Be a member of related professional bodies
Ensure CPD (continual professional development) or similar accreditation requirements are met annually to ensure maintained specialist accreditation
Network key relationships:
Engage with and provide support to the established network of internal and external expert resources and partners
Specialist support to projects:
Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when required
Conform to project management disciplines when participating in projects
Represent department or project on appropriate committees related to area of specialisation
Position Specific Outputs:
Communication with third parties
Approval of all GEMS radiology cases, radiology experience would be advantageous
Review and reassign cases to the correct email or UMS boxes
Compile and maintain weekly statistics.
Daily communication to Business unit Managers, Team leaders - MA availability / Late cover / TAT.
Arrange and/or coordinate second opinions
Obtain discounted quotes
Obtain clinical information by contacting Member/Providers.
Review and refer escalations to Medical advisors
Refer 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 Requirements:
Attribute:
Influence
Entrepreneurship
Credibility
Ownership
Collaboration
Knowledge:
Knowledge and understanding of scheme rules and products
Knowledge of Quality Assurance methodologies
Knowledge of policies and procedures
Skill:
Numerical Ability
Data modelling and evaluation
Attention to Accuracy and Detail
Knowledge and application of relevant legislation
Relevant systems knowledge and application
Problem solving and decision making skills
Computer Technology Skills
Task Management
Executive Business Writing Skills
Adobe Creative Suite
Customer Focus
Communication Skills
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