Clinical Care Coordinator: PMB Reviews and Special Cases

Location: Centurion, Gauteng

Position Purpose: To provide expert clinical assessment and decision making in relation to Prescribed Minimum Benefit reviews, ex gratia applications, regulatory complaints, escalations, and non-disclosure investigations.

Experience: 5 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration Industry or similar.

Solid working experience with the following:

• Prescribed Minimum Benefit (PMB) reviews, Ex Gratia reviews, Council for Medical Schemes (CMS) complaints, non-disclosure investigations, Scheme and social medica escalations of a clinical nature

Qualifications: Registered Nurse with medical diploma/degree and valid SANC registration ( MANDATORY REQUIREMENT )

Accountabilities:

Client service delivery and quality

• Follow procedures and cooperate with peers and leader for best possible service delivery
• Contribute to cost savings within the department to assist with financial goals and targets.

Operation Model

• Meet delivery objectives through working with other team members within and linked to the department / project
• Resolve operational performance variations and problems and elevate unresolved issues to higher levels
• Ensure accuracy and quality of clinical reviews and compliance with regulatory and Scheme requirements.
• Evaluate medical records, ICD10 codes, treatment plans and care pathways Review and assess requests for benefits outside the Scheme rules based on clinical necessity, severity and exceptional circumstances and ensure consistency, fairness and ethical decision making.
• Provide clinical input and analysis for responses to CMS complaints, escalations, and social media complaints and draft clear accurate feedback.
• Review case histories to identify compliance gaps, clinical risk or opportunities for training and development.
• Assess medical evidence to determine material non-disclosure or misrepresentation during underwriting.
• Provide objective evidence based recommendations in line with legislation and Scheme policy
• Maintain a high level of impact on other departments to support improved delivery - Continually increase understanding of client and stakeholder needs, satisfaction and service delivery
• Be a member of related professional bodies
• Ensure CPD (continual professional development) or similar accreditation requirements are met annually to ensure maintained specialist accreditation

Operational Implementation of Strategy

• Keep up to date with operational changes implemented in response to important external influences
• Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
• Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement Operational Leadership
• Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
• Engage in development, coaching and mentoring
• Support transformation through valuing diversity

Stakeholder Management

• Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved
• Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy i
• Liaise with internal teams, treating providers and external stakeholders where required

• Logical exploration of problems with innovative solutions.
• Able to work with, and encourage participation in, team efforts.
• Able to handle concurrent tasks.
• Committed to good business ordinance, maintaining an effective internal control environment.
• Able to manipulate data to produce management information.

• Ability to make healthcare funding decisions that are clinically appropriate, compliant with legislation and Scheme rules, fair to members an aligned with ethical and governance standards.
• Ability to provide defensible clinical recommendations to ensure lawful funding decisions.
• Prepare clinical motivations and recommendations for internal and external committees.
• Evaluate clinical relevance, disease progression and cost reduction strategies without compromising continuity of quality patient care.
• Able to communicate effectively with and favourably influence the actions of others not under their control.
• Negotiation Skills and Telephone Etiquette

Knowledge

• Knowledge and application of processes and procedures and the ability to apply excellent reasoning and analytical skills.
• Knowledge and application of relevant legislation and strong understanding of Prescribed Minimum Benefits and Medical Scheme legislation.
• Product and scheme rule knowledge
• Contribute to continuous improvement of clinical review processes and guidelines.

Skills

• Risk awareness, management and mitigation
• Good business ordinance, maintaining an effective internal control environment
• Time management
• Analytical Ability
• Numerical Ability
• Attention to Accuracy and Detail
• Problem Solving
• Customer Focus
• Communication Skills - both written and verbal
• Ability to work independently and manage multiple complex cases
• Ethical reasoning and fairness
• Emotional intelligence and professionalism

Note: Company reserves the right to close the advert before specified closing date.

PHA has its head office in Westville, KwaZulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.