General description of the Job:

Language: Portugues (Advantageous)

The Clinical Coordinator 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 local clients, and international health insurance members. He/ she will liaise with the Client’s client services contact centre, service providers and other members of the multi-disciplinary team to ensure the best outcome for all members.

Education, Experience and Other requirements:

Grade 12
A Degree or Diploma in Nursing, or other similar medical qualification
2 Years call centre experience an advantage
A post basic specialisation in critical care / Emergency & Trauma / Operating Theatre nursing would be an advantage
Registration with SANC as Professional Nurse / Enrolled Nurse or other medical registration
2 years’ Experience in the Managed Healthcare funding / Administration Industry
Experience with healthcare insurance risk management principles an advantage

Knowledge, skills and attitude:

Sound knowledge Customer Service
Good knowledge of Industry legislation and funding guidelines
Knowledge of Medical Fund/ Health Insurance and healthcare risk management
Clinical Knowledge a must
Good communication skills, verbal and written
Ability to apply knowledge of Legislation to day to day work.
Initiate and implement processes
Participate in protocol and process development
Computer Literacy
Critical evaluation of information
Sound clinical decision making ability
Liaison, coordination and consulting skills
Helpful, friendly and accommodating with a customer focused attitude
Problem Solving
Self-Motivated
Patience and resilience
Assertiveness
Integrity
Flexible and adaptable
Output driven

Duties and Responsibilities included but not limited for all MSO Companies and subsidiaries:

Align clinical activities to the Strategic objectives of the Business Unit.
Work closely with team members and all stakeholders to ensure alignment of activities with client SLA objectives. Manage the entire spectrum of activities from pre-authorization, case coordination, clinical review through to discharge planning, chronic disease management and/or repatriation.
To work shifts and hours as specified by operational requirements. Flexibility is essential.
Ensure that call center service levels are met:
- All ACD calls to be answered in less than 3 rings (under 20 seconds)
- Manage call talk time/ duration to an average of 180 seconds (3 minutes)
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/telecom 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.
Participates in delegated projects
Provide detailed feedback within the prescribed SLA time frame to management
Liaise with clients and service providers as required.

Job Type: Full-time

Education:

Diploma (Required)

Experience:

Managed Healthcare funding / Administration Industry: 2 years (Required)
call centre: 2 years (Required)

Language:

Portuguese (Required)

License/Certification:

SANC, Registered nurse/ Enrolled nurse (Required)

Application Deadline: 2024/04/02

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MSO International (Pty) Ltd

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