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Hospital Benefit Specialist - KZN

Hospital Benefit Specialist - KZN

Discovery LimitedZA
21 days ago
Job description

Job title : Hospital Benefit Specialist - KZN

Job Location : KwaZulu-Natal,

Deadline : October 08, 2025

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Key Purpose :

  • 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 Hospital @ Home, Homecare 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 Patient Services Manager and hospital staff
  • 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 :

  • Attend to patients on daily report
  • Review all low acuity admission requests
  • Quality of processes

    • Competencies :

    The successful candidate must demonstrate the following competencies :

    Role Specific Behaviours

  • Ensures accountability.
  • Action oriented
  • Manages ambiguity.
  • Attracts top talent.
  • Business insight
  • Collaborates
  • Communicates effectively.
  • Manages complexity.
  • Manages conflict.
  • Courage
  • Customer focus
  • Decision quality
  • Develops talent
  • Values differences
  • Directs work.
  • Drives engagement
  • Financial acumen
  • Global perspective
  • Cultivates innovation.
  • Interpersonal savvy
  • Builds networks.
  • Nimble learning
  • Organizational savvy
  • Persuades
  • Plans and aligns.
  • Being resilient
  • Resourcefulness
  • Drives results
  • Demonstrates self-awareness.
  • Self-development
  • Situational adaptability
  • Balances stakeholders
  • Strategic mindset
  • Builds effective teams.
  • Tech savvy
  • Instils trust.
  • Drives vision and purpose
  • Optimizes work processes

    • Education and Experience :

    The following requirements are essential :

  • Matric
  • Must be a Registered Nurse
  • Valid SANC Registration
  • 3 years Clinical experience in a private hospital setting (ICU, Trauma / Casualty, Medical / General ward preferable)
  • 2 years Managed health care experience
  • Microsoft Office (Specifically Excel experience)
  • Valid Driver’s License and own transport ( working hours are between 08 : 30 -17 : 00 & travel up to 50KM may be required)
  • Effective Communication Skills (Verbal & Written)
  • Telephone Etiquette
  • Active Listening Skills

    • The following requirements are advantageous :

  • 1 – 2 years ICU experience
  • Knowledge of DH SOP’s and Process experience (internal only)
  • Provider payment arrangements (internal Only)
  • Clinical coding knowledge of ICD-10 and / or CCSA
  • Medical / Healthcare  jobs
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    Hospital Benefit Specialist Kzn • ZA

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