Hospital Benefit Specialist

Key Purpose:

• 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 all low acuity admission requests
• Quality of processes

Education and Experience:

The following requirements are essential:

• 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 ( working hours are between 08:30 -17:00 & travel up to 50KM may be required)
• Effective Communication Skills (Verbal & Written)
• Telephone Etiquette
• Active Listening Skills

The following requirements are 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

 Personal Attributes or Competency Profile

The Discovery Person

• Values Driven
• Optimistic
• Learns on the Fly
• Resilient
• Instils Trust
• People Savvy
• Drives Results
• Problem Solver