VacanciesHut.online
Website Watershed Consulting
Job Responsibilities:
- All medicines-related issues for special cases and off formulary items.
- Analyse clinical, utilisation, and other data of members and healthcare providers.
- Overall responsibility for incoming calls from Hospitals Case Managers relating to authorisations for procedures in Hospitals, Casualty, Specialist, GP, or Dental provider rooms.
- Hospital case management from issuing a guarantee of payment (GOP) to final discharge and any follow-up treatment where required.
- Share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.
- Identify trends in utilisation, fraud, and other factors.
- Ensure that all calls and cases are fully recorded on the MIP system accordingly.
- Ensure efficient Customer Service and compliance to agreed SLAs.
- Provide input and/or develop other processes to manage utilisation more efficiently.
- Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
- Follow up with GP providers who may be overutilizing the “in rooms” procedures.
Job Requirements:
- At least 2-3 years of experience in a similar role.
- MIP Application System experience and advantage.
- Ability to liaise with external parties – clinicians and members.
- Ability to work within an established team.
- Excellent oral and written communication skills.
- Customer-centric attitude.
- Sound understanding of the South African Health Industry, benefits, options, etc.
- ICD codes, modifiers, and RPL tariff knowledge and understanding.
Qualification & Experience:
- Matric
- Registered Nursing diploma
- Valid membership of SANC
- Claims and Forensic Risk management certification
- Registration with the Association of Certified Fraud Examiners (ACFE SA)
Job Details:
Company: Watershed Consulting
Vacancy Type: Full Time
Job Location: Sandton, Gauteng, SA
Application Deadline: N/A
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