Hospital Benefit Specialist - Gauteng

Gauteng
Permanent
Full-time

2 hours ago

Hospital Benefit SpecialistAbout DiscoveryDiscovery'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 CareDiscovery Care, a subsidiary of Discovery Health, comprises of several specialized clinical areas with segmented teams. The Chronic and PMB Management team handles the processing of Chronic and Prescribed Minimum Benefit requests and manages escalated clinical queries. The HIV/Oncology and In-Hospital Case Management teams review clinical cases specific to their areas of expertise. The High Touch team provides hands-on services and resolves escalated queries for sensitive cases. Additionally, the Hospital Benefit Specialists, as part of field force, are responsible for real-time risk management and the Care Coordination Services manages the Managed Care programs.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☒Ensures accountability.☒Action oriented☒Manages ambiguity.☐Attracts top talent.☒Business insight☒Collaborates☒Communicates effectively.☒Manages complexity.☒Manages conflict.☒Courage☒Customer focus☒Decision quality☐Develops talent☐Values differences☐Directs work.☐Drives engagement☐Financial acumen☐Global perspective☒Cultivates innovation.☒Interpersonal savvy☒Builds networks.☒Nimble learning☒Organizational savvy☒Persuades☒Plans and aligns.☒Being resilient☒Resourcefulness☐Drives results☒Demonstrates self-awareness.☒Self-development☒Situational adaptability☐Balances stakeholders☐Strategic mindset☐Builds effective teams.☐Tech savvy☐Instils trust.☐Drives vision and purpose☐Optimizes work processesEducation 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 ProfileThe Discovery Person

Values Driven
Optimistic
Learns on the Fly
Resilient
Instils Trust
People Savvy
Drives Results
Problem Solver

EMPLOYMENT EQUITYThe 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.

Discovery

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