Current Jobs at Discovery Limited

Key Purpose:

• Management of enrolled Oncology members by reviewing clinical appropriateness of treatment is prescribed. This involves the correct application of Clinical Entry Criteria, Protocols, SOP’s and Clinical guidelines as well as explaining the benefit to the member and counselling the member.

Key Outputs:

The successful applicant will be responsible for but not limited to the following job functions:

• Enroll Member on Oncology Program and ensure that the member meets all requirements to qualify for the benefit (i.e. Forensics, Underwriting categories)
• Review treatment plans in line with the SAOC and Icon guidelines
• Approve treatment in line with SAOC/Icon as well as Discovery Health protocol.
• Decline treatment which is not in line with SAOC\ICON as well as internal Discovery Health protocol.
• Refer complex cases to internal and external Medical Review teams and provide feedback to both members and Providers.
• Communicate funding decisions to members, employers and brokers verbally or in writing.
• Make comprehensive notes on treatment that was approved/declined and how the funding decision was made.
• Mitigate risk by using clinical knowledge to identify risk and reporting it accordingly.
• Provide support to members, CHO Service Agents, Doctors and Pharmacist.
• Support to Doctors by coordinating treatment plans and sending them updated guidelines and information.
• Meeting daily Operational targets.

Education and Experience:

The following requirements are essential:

• Matric
• Registered & Enrolled Nurse
• Registered with SANC
• 2 years Clinical experience
• Knowledge of Oncology Treatment Interventions
• Microsoft Office
• Effective communication skills (verbal & written)
• Effective presentation skills
• Telephone Etiquette
• Active listening skills

The following requirements will be advantageous:

• 1-year experience as a Case Manager.
• DH systems and products.

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Key Purpose

• This role falls within the Discovery Group Forensics department and reports to the General and Divisional Manager.  The successful candidate will be required to investigate all issues pertaining to healthcare fraud

Areas of responsibility may include but not limited to:

• Investigating allegations of healthcare fraud against Discovery
• Doing administrative tasks
• Following up on leads regarding allegations of healthcare fraud
• Conducting investigations into all aspects pertaining to healthcare fraud
• Instituting measures to prevent fraud
• Confronting perpetrator/s and taking necessary action where applicable
• Analyzing data to identify possible fraudulent trends i.e. coding, drugs analysis etc.
• Collecting, evaluating and handling of evidence
• Ability to identify fraudulent/suspicious claims profiles

Personal attributes and skills – Discovery Person

• Plans activities and projects well in advance and takes account of possible changing circumstances
• Easily establishes good relationships with customers and staff
• Ability to communicate clearly and concisely
• Focuses on customer needs and satisfaction
• Probes for further information or greater understanding of a problem
• Assertive
• Takes initiative and works under own direction
• Keeps emotions under control during difficult situations
• Diplomatic
• Knowledge of Medical Aid industry
• Good understanding of healthcare legislation

Education and Experience

Minimum:

• 2 years’ experience in the healthcare environment
• Clinical qualification
• Good understanding of claims and NHRPL coding
• Understanding of healthcare investigations