Hospital Benefit Specialist
About Discovery
Discovery's core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.
About Discovery Care
Discovery Care is a subsidiary for Discovery Health - made up of 8 distinct areas with segmented teams responsible for the processing of specialized claims, CIB queries and escalated clinical queries processes while our case management teams are responsible for reviewing clinical cases for each of the specialized areas. Our clinical services area is also responsible for all council disputes while our high touch team provide hands on services and escalated query resolution to sensitive cases.
Key Purpose:
The successful applicant will be responsible for but not limited to the following job functions:
• Assessing the case in relation to the following:
Members clinical history
Members benefit structure
Clinical Information and coding supplied
Level of care provided
Appropriateness of the facility
Appropriateness of the treating doctor
Appropriateness of treatment
• Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care
• Discharge planning by providing the member with alternatives to receive treatment (This includes Hospital @ Home, Homecare etc.)
• Effective and accurate communication to all stakeholders:
Case update to the provider
Funding decisions and benefit confirmation to the members
Request for additional information from the treating doctor or practice manager
Engaging with Patient Services Manager and hospital staff
Handling escalations from Providers and internal stakeholders
Preparing and presenting complex case to clinical review
Trend Analysis of inefficiencies and proposals to correct
Appropriate internal case referrals for clinical management
• Operational Targets:
Attend to patients on daily report
Review all low acuity admission requests
Quality of processes
Competencies:
The successful candidate must demonstrate the following competencies:
Role Specific Behaviours
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Ensures accountability.
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Action oriented
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Manages ambiguity.
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Attracts top talent.
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Business insight
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Collaborates
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Communicates effectively.
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Manages complexity.
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Manages conflict.
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Courage
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Customer focus
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Decision quality
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Develops talent
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Values differences
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Directs work.
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Drives engagement
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Financial acumen
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Global perspective
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Cultivates innovation.
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Interpersonal savvy
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Builds networks.
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Nimble learning
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Organizational savvy
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Persuades
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Plans and aligns.
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Being resilient
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Resourcefulness
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Drives results
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Demonstrates self-awareness.
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Self-development
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Situational adaptability
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Balances stakeholders
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Strategic mindset
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Builds effective teams.
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Tech savvy
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Instils trust.
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Drives vision and purpose
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Optimizes work processes
Education and Experience:
The following requirements are essential:
Matric
Must be a Registered Nurse or Clinical Associate
Valid SANC Registration or HPCSA registration
3 years Clinical experience in a private hospital setting (ICU, Trauma/Casualty, Medical/General ward preferable)
2 years Managed health care experience
Microsoft Office (Specifically Excel experience)
Valid Driver's License and own transport ( working hours are between 08:30 -17:00 & travel up to 50KM may be required
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Effective Communication Skills (Verbal & Written)
Telephone Etiquette
Active Listening Skills
The following requirements will be advantageous:
1 – 2 years ICU experience
Knowledge of DH SOP's and Process experience (internal only)
Provider payment arrangements (internal Only)
Clinical coding knowledge of ICD-10 and/or CCSA
Personal Attributes or Competency Profile
The Discovery Person
Values Driven
Optimistic
Learns on the Fly
Resilient
Instils Trust
People Savvy
Drives Results
Problem Solver
EMPLOYMENT EQUITY
The Company's approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.
