Hospital Benefit Specialist

Overview

Hospital Benefit Specialist - Gauteng

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 Discovery Care

Discovery Care, a subsidiary of Discovery Health, comprises of several specialized clinical areas with segmented teams. The Chronic and PMB Management team handles the processing of Chronic and Prescribed Minimum Benefit requests and manages escalated clinical queries. The HIV / Oncology and In-Hospital Case Management teams review clinical cases specific to their areas of expertise. The High Touch team provides hands-on services and resolves escalated queries for sensitive cases. Additionally, the Hospital Benefit Specialists, as part of field force, are responsible for real-time risk management and the Care Coordination Services manages the Managed Care programs.

Key Purpose

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

Responsibilities

• Assessing the case in relation to the following : Members clinical history
• Assessing the case in relation to the following : Members benefit structure
• Assessing the case in relation to the following : Clinical Information and coding supplied
• Assessing the case in relation to the following : Level of care provided
• Assessing the case in relation to the following : Appropriateness of the facility
• Assessing the case in relation to the following : Appropriateness of the treating doctor
• Assessing the case in relation to the following : 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 Hospital @ Home, Homecare etc.)
• Effective and accurate communication to all stakeholders : Case update to the provider
• Effective and accurate communication to all stakeholders : Funding decisions and benefit confirmation to the members
• Effective and accurate communication to all stakeholders : Request for additional information from the treating doctor or practice manager
• Effective and accurate communication to all stakeholders : Engaging with Patient Services Manager and hospital staff
• Effective and accurate communication to all stakeholders : Handling escalations from Providers and internal stakeholders
• Effective and accurate communication to all stakeholders : Preparing and presenting complex case to clinical review
• Effective and accurate communication to all stakeholders : Trend Analysis of inefficiencies and proposals to correct
• Effective and accurate communication to all stakeholders : Appropriate internal case referrals for clinical management
• Operational Targets : Attend to patients on daily report
• Operational Targets : Review all low acuity admission requests
• Operational Targets : Quality of processes

Competencies

The successful candidate must demonstrate the following competencies :

Role Specific Behaviours

Education and Experience

The following requirements are essential :

The following requirements are advantageous :

Personal Attributes or Competency Profile

The Discovery Person

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.

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