Clinical Consultant needed immediately: Salary R25 000 to R28 000 a month
General description of the Job:
The Clinical Consultant will work closely with the Clinical and Admin members of the International team to ensure alignment of activities as well as the achievement of client Service level objectives. He/ she is also responsible for the management of all pre-authorisation and medical assistance requests for International health insurance members. He/ she will liaise with the Client’s client services contact center, service providers and other members of the multi-disciplinary team to ensure the best outcome for all members.
Education & Experience
A minimum requirement of Grade 12.
A degree or Diploma in Nursing
A post basic specialization/Experience in Critical care / Emergency & Trauma/ Operating Theatre Nursing is preferred
Registration with the SANC as a Professional Nurse/ Enrolled Nurse
Additional Inherent Job Requirement
Successful Candidate must be fluent in SETSWANA**
Preferred at least 2 years’ experience within the Managed Healthcare funding / Administration Industry
Knowledge of health insurance and healthcare risk management
Core Competencies & Inherent Requirements
Good communication skills, verbal and written
Report writing skills
Helpful, friendly and accommodating
A Customer focused attitude
Knowledge of Industry legislation and funding guidelines
Ability to apply knowledge of legislation to day-to-day work.
Initiate and implement processes.
Participate in protocol and process development.
Self-motivated, self-starter with a “go- getter” attitude
Medical Aid/ Health Insurance products and benefits
Provide authorisation within the policy guidelines and benefit rules
Clinical Knowledge as it applies to the diagnosis, treatment and medical care
Critical evaluation of information
Ability to identify potential claims risk.
Sound clinical decision making ability
Liaison, coordination and consulting
Preparation of clinical status reports
Collation of medical reports for review by Medical advisor/ Funder
Life long learner
Duties and responsibilities:
Align activities to the Strategic objectives of the Business Unit.
Work closely with other team members to ensure alignment of activities with client SLA objectives.
Ensure that call centre service levels are met:
All ACD calls to be answered in less than 3 rings (under 20 seconds)
Manage call talk time/ duration to at least 180 secondss ( 3 minutes)
Ability to work shifts and hours as specified by client requirements.
Accept pre-authorisation requests telephonically, e-mail/fax:
verify membership validity
verify benefit available for treatment requested as per scheme/ Insurers benefit rules
Assess medical necessity of treatment, appropriateness of facility, service provider and level of care – refer to medical protocols ,consult with Clinical Manager / Medical Advisor as required or if uncertain
Approve /decline request and communicate appropriately with member/ service providers
Update cases – based on utilisation review and clinical updates from hospital
Attend to daily tasks as delegated, i.e. mail-box , daily pended status reports
Liaise with scheme contact persons on funding decisions as required.
Provide detailed feedback within the prescribed SLA time frame to clients.
Co-ordinate on-site Case management visits as may be required from time-time to monitor, level of care, utilisation review, discharge planning / negotiation with hospital admin/ Treating Specialists.
Job Type: Full-time
Salary: R25,000.00 to R28,000.00 /month
Managed Healthcare Funding: 2 years (Required)
Health Insurance and Healthcare Risk Management: 1 year (Preferred)
Theatre Nursing: 1 year (Preferred)
High School (matric) (Required)