Reporting to: Team Leader

Position Type : Permanent

Location : Centurion, Gauteng

Position Purpose: To manage the spending of member funds by means of clinical interventions and managed care protocols.

Experience: At least 3 years general medical and surgical nursing experience in the private sector. ICU training and/or at least 1 year ICU nursing experience and 1 year hospital case management experience will be advantageous. In conjunction with above, at least 18 months hospital pre-authorisation experience.

Qualifications: Professional Registered Nurse with valid up to date registration with the South African Nursing Council (MANDATORY REQUIREMENT)

KEY PERFORMANCE AREAS

Member Assessment and Care Coordination

• Review member medical records, treatment plans, and claims to assess care needs.
• Coordinate care with healthcare providers, including doctors, hospitals, and allied health professionals.
• Develop and implement individualised care plans for members with chronic conditions, complex medical needs, or high-cost cases.

Clinical Review and Authorisation

• Evaluate clinical information to determine medical necessity and appropriateness of treatments.
• Approve, deny, or escalate authorisations in accordance with medical aid guidelines and protocols.
• Monitor ongoing treatment plans to ensure optimal outcomes and cost-effectiveness.

Member Support and Education

• Provide guidance and support to members on their treatment options, benefits, and preventive care.
• Educate members on managing chronic conditions and adhering to treatment plans.
• Act as the primary contact for members’ healthcare queries and concerns.

Provider Engagement

• Liaise with healthcare providers to clarify clinical information and coordinate care.
• Promote compliance with evidence-based medical guidelines.
• Facilitate referrals to specialists, rehabilitation, or support services as required.

Reporting and Documentation

• Maintain accurate and up-to-date records of member interactions, care plans, and authorisations.
• Compile reports on case management outcomes, cost savings, and member satisfaction.
• Ensure compliance with regulatory and organisational policies, including POPIA and medical confidentiality requirements.

Continuous Improvement

• Identify trends in member utilisation and outcomes, recommending improvements in care management processes.
• Participate in training, development, and quality improvement initiatives.

KEY COMPETENCIES

Knowledge

• Knowledge and application of dispensing of meds, surgical material & procedures
• Application of financial and risk assessment methodology
• Knowledge of scheme rules and contractual negotiations
• Application of clinical intervention principles
• Advise on best practice health risk solutions to relevant parties
• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedure

Skills

• Member-focused and empathetic.
• Attention to detail and accuracy in clinical assessment.
• Ability to prioritise and manage multiple cases simultaneously.
• Problem-solving and conflict resolution skills.
• Strong collaboration with internal teams and external healthcare provider
• Attention to Accuracy and Detail

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