Job Description

Job Summary Minimum Education: Nursing Qualification (Nursing Diploma as a registered nurse)Minimum Experience: 3 to 5 years (previous pre-authorisation, case management experience in a managed healthcare environment is essential)Duties and Requirements includes but is not limited to the following:

• Knowledgeable of the Medical Schemes Act and Government Gazette on tariffs
• Conduct telephonic assessment, competency assessments and first line interviews during recruitment
• Responsible for the training of all new staff recruits in the areas of clinical assessing/auditing, pre-authorisation and specialised case management
• Providing detailed training feedback post probation
• Responsible for identifying and meeting training needs of existing staff
• Responsible for identifying and updating system and process enhancements throughout the department
• Review and update training manuals, guidelines, standard operating procedures (SOP's) and cheat sheets
• Maintain quality control for Clinical auditing staff and provide monthly feedback and stats to senior manager
• Monitor workload to ensure SLA's are met
• Involvement with any complex hospital/ associated account queries leading to resolution and reconciliation of the account
• Assist with all HR issues ie: performance counselling, change management etc.
• System testing:

• Responsible for testing any system programming changes that affect the department
• Identify staff members who display an aptitude for testing and develop their testing abilities
• Data Mining:

• Involvement with the data mining process from a statistical point of view within the areas of trends, costs and disease management, amongst others
• Review of data for the Annual statutory return of the scheme to Council for Medical schemes

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