Jobs at Discovery Limited

This position requires the successful candidate to manage legal disputes, as well as to provide legal assistance to Discovery Health when necessary.

Key Outputs

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

• Argue cases at Disputes on behalf of DHMS at weekly Dispute Hearings.
• Manage and own the entire Dispute Process and the relevant workflow pools.
• Assist senior legal advisor to respond to legal letters of demand from members.
• Provide legal assistance in respect of appeals to Council.
• Assist senior legal advisor in managing the mediation process before a matter goes on appeal.
• Provide legal training to the Benefit Compliance Review team when required.
• Update the Benefit Compliance Review team and relevant business areas on Council for Medical Schemes and dispute rulings as required.
• Monthly and quarterly trending and status reports.
• Assist in and provide advice on legal matters pertaining to Discovery Health e.g. Application of the Medical Schemes Act and Regulations to funding decisions.
• Draft heads of arguments for appeal and dispute matters.
• Investigate cases prior to going for disputes.
• Track industry trends relating to the Appeal committee and to the appeal board decisions, to assist with the implementation into Discovery Health.
• Record keeping according to company requirements.

Competencies

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.

Priority Setting: Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.

Planning: Accurately scopes out length and difficulty of tasks and projects; sets objectives and goals; breaks down work into the process steps; develops schedules and task/people assignments; anticipates and adjusts for problems and roadblocks; measures performance against goals; evaluates results.

Managerial Courage: Doesn't hold back anything that needs to be said; provides current, direct, complete, and "actionable" positive and corrective feedback to others; lets people know where they stand; faces up to people problems on any person or situation (not including direct reports) quickly and directly; is not afraid to take negative action when necessary.

Action-Oriented: Enjoys working hard; is action oriented and full of energy for the things he/she sees as challenging; not fearful of acting with a minimum of planning; seizes more opportunities than others.

Organizational Agility: Knowledgeable about how organizations work; knows how to get things done both through formal channels and the informal network; understands the origin and reasoning behind key policies, practices, and procedures; understands the cultures of organizations.

Interpersonal Savvy: Relates well to all kinds of people—up, down, and sideways, inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can defuse even high-tension situations comfortably.

Qualifications & Experience

The following requirements are Essential:

• Matric
• LLB qualification
• At least 1 year working experience in the medical schemes environment
• Knowledge of Managed Care Environment
• Excellent written and verbal communication skills in English
• Basic computer literacy in Microsoft Office applications (must be proficient in Excel)
• Drafting of legal documents eg. Heads of Argument, opinions and legal letters

The Following Requirements Are Advantageous

• Knowledge of Discovery Health Medical Scheme and In-House products and protocols
• At least two years experience in large law firm
• Clinical /Medical knowledge

go to method of application »

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