Hospital Benefit Specialist

 

About Discovery

 

Discovery’s core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.

 

About Discovery Care

 

Discovery Care is a subsidiary for Discovery Health - made up of 8 distinct areas with segmented teams responsible for the processing of specialized claims, CIB queries and escalated clinical queries processes while our case management teams are responsible for reviewing clinical cases for each of the specialized areas. Our clinical services area is also responsible for all council disputes while our high touch team provide hands on services and escalated query resolution to sensitive cases.

 

 

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 or Clinical Associate Valid SANC Registration or HPCSA 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 will be 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

 

EMPLOYMENT EQUITY   
                             
The Company’s approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.