Medical Services Organisation | Case Manager

Discovery Health | Africa Health Hub

Medical Services Organisation | Case Manager 

About Discovery

Discovery’s core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.

About The Discovery Africa Team

Discovery Africa is a subsidiary of Discovery Health and strategically extends Discovery’s reach through delivery in key business activities:

Provision of Health insurance products underpinned by Vitality and Shared value principles, targeting growth across the African continent. Products are currently sold in: DRC, Mozambique, Kenya, Zambia, Ghana, Nigeria and Tanzania.

Third Party Administration services provided to global, multi-national insurance organisations. Coverage extends to all countries on the African continent (except CAR and Guinea Bissau)

24/7 Medical assistance to inbound travellers to South Africa and outbound travellers to the rest of the world. This includes Discovery Health members covered under the international travel benefit (ITB).

Key Purpose:

 Managing the risk relating to In hospital admissions, through the application of clinical knowledge and protocols, legislation, standard operating procedures (SOP’s), service level agreements (SLA’s) and the member’s benefit structure.

Key Outputs:

 The successful applicant will be responsible for but not limited to the following job functions:

 Assessing the case in relation to the following: 

• Members clinical history
• Members benefit structure
• Clinical Information and coding supplied
• Level of care provided
• Appropriateness of the facility
• Appropriateness of the treating doctor
• Appropriateness of treatment

• Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care

• Discharge planning by providing the member with alternatives to receive treatment (This includes Homecare, CCP etc.)

• Effective and accurate communication to all stakeholders:

• Case update to the provider
• Funding decisions and benefit confirmation to the members
• Request for additional information from the treating doctor or practice manager
• Engaging with Hospital Case Managers and Doctors

• Handling escalations from Providers and internal stakeholders
• Preparing and presenting complex case to clinical review
• Trend Analysis of inefficiencies and proposals to correct
• Appropriate internal case referrals for clinical management

Operational Targets:

• SLA, e.g. TWT, DPMO 

Competencies:

 The successful candidate must demonstrate the following competencies:

Education and Experience:

The following requirements are essential:

• Matric
• Enrolled or Registered Nurse
• Current registration with the South African Nursing Council
• 2-years exposure to an in-hospital setting
• Experience with healthcare insurance risk management
• Experience with healthcare insurance
• 6 month’s consistent performance in current role

Skills:

• Computer and Microsoft Office skills
• Effective Communication Skills (Verbal & Written)
• Telephone Etiquette
• Active Listening Skills
• Clinical reasoning
• Critical thinking
• Problem-solving

The following requirements are advantageous:

• In Hospital Clinical CRM experience
• 1-year Managed health care experience
• 1-year Trauma / ICU exposure

EMPLOYMENT EQUITY   
                             
The Company’s approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.