Jobs at Momentum

Role Purpose    
Provide an effective and efficient service to providers and members by administering the process of chronic diagnosis and medicine authorization and to give support to the DUR Pharmacists and other Health teams for the various clients under the administration of MHS.

Requirements    

• Matric
• Post Basic Pharmacist Assistant qualification registered with the South African Pharmacy Council essential
• Minimum of 3 years experience essential
• Adequately knowledgeable about chronic disease medication (Clinical knowledge)
• Computer Literate (MS Office, Outlook, Excel, Word)
• Previous experience with chronic medicine management in a Managed Care environment would be an advantage
• Being able to speak more than one language advantageous

Duties & Responsibilities    

• Must handle members and providers and internal stakeholders professionally
• Real time provider interaction and decision making is essential
• Registration of chronic conditions, treatment and medicine is done timeously and independently in line with clinical policies, clinical guidelines and relevant scheme rules.
• Engage in effective communication and delivery according to Service Level Agreement
• Provide first time resolution on queries, escalations sent to the MRM department and resolve them timeously
• Consistently maintain a 24 hour turnaround time from receipt of documents / calls into correspondence workflow
• Maintaining productivity levels and deliver on Service levels as per agreement with internal and external clients in order to ensure that client expectations are managed
• Conducting drug utilization review (DUR) processes according to clinical and internal protocols
• Involved in Pre-authorization requests as part of the one stop authorization center if need be.
• Ensure effective claims management service delivery and support
• Perform an efficient and accurate administrative function e.g. handling correspondence, rejection letters, member and provider letters and emails
• Identify all compliance risks related to chronic diseases and manage the lifestyle changes of the member to ensure healthy outcomes
• Enlist the support of the Lifestyle and Wellness teams to manage the client or patient and if need be support them in managing health outcomes for the member
• Identify and investigate all possible non-disclosure of pre-existing conditions
• Ensure the consistent and correct application of exclusions
• Identify the appropriate clinical, chronic, hospitalization and PMB entry criteria
• Ensure cost effective processing of competitive prescription claims
• Develop effective relationships with stakeholders at all levels of MHS, including 3rd parties and service providers and provide expert advice to internal and external stakeholders
• Monitor customer delivery constraints and escalate exceptions to management
• Establish, develop and maintain productive and collaborative working relationships with team members, peers and other stakeholders and assist where necessary to achieve personal and team excellence
• Work as part of the team to provide effective service delivery to an assigned area
• Self-development – Incumbent is expected to take ownership for driving career and personal development and to progress steadily through the various training options available internally and externally and to continuously develop own expertise in terms of professional, industry and legislation knowledge
• Make recommendations to improve client service and fair treatment of clients within area of responsibility
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Contribute to the financial planning process within area and identify opportunities to enhance cost effectiveness and increase operational efficiency
• Manage financial and other company resources under your control with due respect
• Provide input into the risk identification processes and communicate recommendations in the appropriate forum
• Appropriately communicating related aspects of the programme to internal and external parties

Competencies    

• Sound communication skills ( both verbal and written)
• Problem-solving
• Effective planning, prioritising and co-ordinating abilities
• A highly client-focused approach, able to build and maintain good relationships
• Ability to consistently work efficiently and accurately especially under pressure

Closing Date: 15th, June 2022