Hospital Benefit Specialist at Discovery Limited

Key Purpose

Managing the risk relating to In hospital admissions, through the application of clinical and coding knowledge, protocols, legislation, standard operating procedures (SOP’s), service level agreements (SLA’s) and the member’s benefit structure. The role will apply to working in various settings, predominantly casualty. It is anticipated that the risk purpose will also extend into the general ward and high care/ICU settings as needed.
Coordinating the care of certain patients who are vulnerable to care gaps during transitions particular entry into hospital through to the emergency room, and discharge from hospital. The populations most vulnerable to gaps in care during transitions include clinically high risk patients; patients undergoing major surgical procedures; and patients with low socio-economic circumstances.

Please note: The successful applicants will be based at a designated hospital within the applicable region.

Principal Accountabilities
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 approving or declining treatment to ensure that the member gets the appropriate level of care
• Discharge planning by providing the member with alternatives to receive treatment
• Effective and accurate communication to all stakeholders:
• Case update to the provider
• Funding decisions and Benefit confirmations to the members
• Request for additional information from the treating doctor
• Systems teams (issues experienced)
• 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
• Quality of processes
• Onsite perception survey
   

Personal Attributes

• Composure - Is cool under pressure; does not become defensive or irritated when times are tough; is considered mature; can be counted on to hold things together during tough times; can handle stress; is not knocked off balance by the unexpected; doesn't show frustration when resisted or blocked; is a settling influence in a crisis.
• Conflict Management - Steps up to conflicts, seeing them as opportunities; reads situations quickly; good at focused listening; can hammer out tough agreements and settle disputes equitably; can find common ground and get cooperation with minimum noise.
• Decision Quality – Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions.
• Integrity and Trust - Is widely trusted; is seen as a direct, truthful individual; can present the unvarnished truth in an appropriate and helpful manner; keeps confidences; admits mistakes; doesn't misrepresent him/herself for personal gain.
• Negotiating - Can negotiate skillfully in tough situations with both internal and external groups; can settle differences with minimum noise; can win concessions without damaging relationships; can be both direct and forceful as well as diplomatic; gains trust quickly of other parties to the negotiations; has a good sense of timing.
• Perseverance - Pursues everything with energy, drive, and a need to finish; seldom gives up before finishing, especially in the face of resistance or setbacks.
• Problem Solving - Uses rigorous logic and methods to solve difficult problems with effective solutions; probes all fruitful sources for answers; can see hidden problems; is excellent at honest analysis; looks beyond the obvious and doesn't stop at the first answers.

The Following Requirements Are Essential

Education and Experience:

• 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
• 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