Registered Nurse with case management experienced needed in the insurance sector!
Scope of Responsibility:
• Overall responsibility for incoming calls from Hospitals Case Managers relating to authorisations for procedures in Hospitals, Casualty, Specialist, GP, or Dental provider rooms.
• Hospital case management from issuing a guarantee of payment (GOP) to final discharge and any follow-up treatment where required.
• All medicines-related issues for special cases and off formulary items.
• Analyse clinical, utilisation, and other data of members and healthcare providers.
• Share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.
• Identify trends in utilisation, fraud, and other factors.
• Ensure that all calls and cases are fully recorded on the MIP system accordingly.
• Ensure efficient Customer Service and compliance to agreed SLAs.
• Follow up with GP providers who may be overutilizing the “in rooms” procedures.
• Manage and maintain data integrity and update accordingly where necessary.
• Provide input and/or develop other processes to manage utilisation more efficiently.
• Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
• Regularly review all approved claims and ensure that all are settled according to correct tariffs and procedures.
• Supply all monthly management reports.
• Any other duties as assigned by the company from time to time.
• Registered Nursing diploma
• Valid membership of SANC
• Claims and Forensic Risk management certification
• Registration with the Association of Certified Fraud Examiners (ACFE SA)
Skills and Experience:
• At least 2-3 years of experience in a similar role.
• MIP Application System experience and advantage.
• Sound understanding of the South African Health Industry, benefits, options, etc.
• ICD codes, modifiers, and RPL tariff knowledge and understanding.
• Ability to liaise with external parties – clinicians and members.
• Ability to work within an established team.
• Excellent oral and written communication skills.
• Customer-centric attitude.
• Excellent analytical skills and pays attention to detail.
• Computer literate - MS Office suite, i.e. Word, Excel.
• A good understanding of claims risk profiling.
• Experience in claims auditing.