Talent Pool: Hospital Benefit Specialist at Discovery Limited

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