Talent Pool: Clinical Specialist MMH251118-9Momentum • Centurion, Gauteng, South Africa

Talent Pool : Clinical Specialist MMH251118-9

Momentum • Centurion, Gauteng, South Africa

8 days ago

Job description

Talent Pool : Clinical Specialist MMH -9

Location : Momentum Centurion, Gauteng, South Africa

Role Purpose : Accountable for clinical risk management processes, operationalizing process improvements, interpreting requirements from stakeholders and collaboratively constructing meaningful rules and data mapping requirements for BSS configuration and business transformation, ensuring alignment of business processes to service delivery.

Requirements

Matric or Grade 12 as minimum requirement
Qualification as a Registered Nurse and registered with SANC (essential)
Training or coaching qualification (advantageous)
3‑5 years operational experience (essential)
3‑5 years experience in Managed Health Care, especially CMS requirements, Medical Schemes Act, regulations, guidelines, accreditation standards (essential)
Claims assessing experience (advantageous)
Experience in interpreting and applying scheme rules correctly

Attributes

Knowledge of the NHRPL, SAMA tariffs, ICD‑10, CPT (CCSA) coding (advantageous)

Deep knowledge of the Medical Schemes Act and relevant regulations

Strong communication skills (written & verbal)

Computer literacy (email, Word, Excel)

Commitment to diversity and inclusiveness

Collaboration, adaptability, results‑driven

Teamwork, proactive, ability to work under pressure

Strong organizational skills, attention to detail, high accuracy

Ability to multitask

Duties and Responsibilities

Internal Process

Engage business stakeholders on operational processes (products, systems, content, processes) to improve business outputs

Review clinical and technical data, identify better data collection requirements, analyze trends to develop rule sets increasing straight‑through processes

Map data and implement new data collection requirements to enhance data visualisation outputs

Design content for skillful rule authoring for operational and system processes

Identify training needs of business teams and collaborate with leaders to address gaps

Conduct gap analysis and provide feedback to team members and managers

Update department process documents and library annually

Input to update training material for employee effectiveness

Liaise with trainers to ensure accurate, up‑to‑date training material

Deliver on service level agreements with clients and stakeholders, manage expectations

Develop and maintain productive relationships with peers and stakeholders

Influence and participate in change initiatives

Continuously develop expertise in professional, industry, and legislation knowledge

Client Service

Build and maintain relationships with clients and internal stakeholders

Deliver on SLAs for clients and stakeholders, ensuring expectations managed

Make recommendations to improve client service and fair treatment of clients

Contribute to culture building rewarding relationships, facilitating feedback, exceptional client service

Monitor turnaround times and quality standards, resolve issues quickly to enhance delivery

Drive client service delivery goal achievement to ensure appropriate advice and after‑sales service

Manage client query processes, ensuring accurate resolution and improvement of service

People

Build strong relationships through specialist know‑how and leadership

Continuously develop expertise in industry and subject matter development

Positively influence and manage change, offer specialist support where needed

Contribute to innovation through new ideas and colleague involvement

Participate in culture of work‑centric thinking, productivity, service delivery, quality management

Take ownership of driving career development

Finance

Contribute to area‑specific budget development to minimise expenditure, aligned with operational plans

Identify solutions to enhance cost effectiveness and increase operational efficiencyl

Implement and provide input into governance processes, systems and legislation within the area

Escalate unresolved policy and governance compliance issues appropriately

Provide input into risk identification processes and communicate recommendations

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Talent Specialist • Centurion, Gauteng, South Africa

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