Key Outcomes 

Responsibilities include:

• Ensuring service level agreements are met.
• Answering calls routed through for casualty or hospital treatment and admission. 
• Identify exclusions from the onset of request for treatment.
• Ensure that correct benefit is utilised by member.
• Correct level of care is allocated to the correct facility.
• Latest medical guidelines are used within the available benefit.
• Reporting on cases actioned per month including savings.
• Report any clinical escalations/concerns to the clinical Review team.
• Act as a patient advocate  
• Maintain all the confidentiality in clinical conditions shared with her/him.
• Review latest appliances used in hospital against the current treatment guidelines.
• Educate patients on benefit and limitations on their insurance option.
• Developing referral and treatment protocols for new or updated conditions identified.
• Discussing diagnosis with doctors, specialists and other health care providers,
• Conducting assessments of patient needs, such as mental health issues or substance abuse problems and refer to EAP where applicable.
• Providing information about treatment options, side effects, and possible complications of medications or procedures
• Assisting with monthly reporting on statistics
• Utilize all resources and guidelines at his/her disposal to effectively assess, prioritize, advise, and manage patients admitted.
• Thoroughly complete documentation utilizing the appropriate computer software in compliance with the approved policies and procedures.
• Maintain current nursing skills and knowledge base by attendance at workshops and seminars, completion of mandatory continuing education, reading of professional journals, publications, and participation in professional organizations.

Qualifications

Required

• Registered Nurse
• Degree /Diploma in Nursing
• ICU/Operation theatre trained, or experience is an advantage.
• 2 years hospital Case Management experience would be beneficial.
• Medical Aid or Insurance industry experience will be an advantage.
• Sound knowledge of ICD and CPT coding and DRG’s

Preferred

• Professional Nurse with SANC registration
• Prefer minimum of three years recent clinical experience in health, critical care and/or emergency room.
• Familiarity/experience with patient interactions on the telephone
• Strong communication and interpersonal skills