Introduction
Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
Role Purpose
Ensure comprehensive clinical risk management training, mentoring, and skills development, aligning business processes and system capabilities to optimise service delivery and achieve departmental and individual objectives.
Requirements Matric Nursing Qualification (Registered Nurse) Minimum of 5 years Clinical experience Registered with the SANC Minimum 3 years medical aid industry knowledge Pharmacology knowledge Computer literate and competent in Word / Excel Knowledge of Oracle system (workflow, association of documents) an advantage Good understanding of the medical scheme rules and regulations Knowledge of new medical technology Basic understanding of legislation relating to PMB and its application Good Written and oral communication skills Duties & Responsibilities Manage all complex clinical cases and requests for additional information from providers and members. Research all data available regarding a request / appeal. Make clinically appropriate decisions pertaining to letters of motivation from providers. Deal with member and doctor queries. Document decisions (update Workflow). Telephonically resolve queries where applicable. Answer queries referred by Contact Centre, Pre-Authorisation, Scheme office and fund management, members and providers. Produce stats and reports required by the schemes. Competencies Ability to converse confidently with members, doctors, and brokers. Excellent communication skills (telephonic, verbal, and written). Research and investigational skills. Professional attitude. Sound decision-making ability. Integrity and confidentiality.
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