Hospital Benefit Specialist
Discovery Limited · Durban, KwaZulu-Natal
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Start free — we apply for you →Key Purpose
The successful applicant will be responsible for but not limited to the following job functions:
- The successful applicant will be based in Durban.
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
Education and Experience
The following requirements are essential
- Matric
- Must be a Registered Nurse
- Valid SANC 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
- Effective Communication Skills Verbal & Written
- Telephone Etiquette
- Active Listening Skills
The following requirements are 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