Hospital Benefit Specialist- KZN at Discovery Limited

Key Outputs

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 a minimum of 50% of daily low acuity admission requests
• Quality of processes
• Onsite perception survey

Personal Attributes

• Emotional Intelligence - Ability to understand, use, and manage emotions in positive ways to communicate effectively, empathise with others and defuse conflict.
• 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