Case Manager - Medical Advisor

Position Purpose:

To facilitate the setting of quality standards, policies, and procedures (clinical and non-clinical) for area. Ensure adherence to audit requirements, reporting and planning through evaluation, and coaching internal resources.

Experience:

5 years’ experience in the Managed Care environment in pre-authorisation call centre/ hospital case management or hospital claims. Working experience with a team of medical advisors will be an added advantage.

Qualifications

Enrolled or Registered Nurse

Generic Output Details

Accountabilities

Continuous improvement:

Review and write clinical rules and processes

Develop clinical policies, procedures and and maintain other business rules related to business unit, to ensure optimal automation

Systematically monitor and review all policy changes

Demonstrate independent decision making in the evaluation and feasibility of requests for system improvements and policies / processes

Interact with team members at all levels of the business in decision making

Liaise with all other Service Network Providers and Medscheme Operational areas to successfully develop Standard Operating Procedures

Deliver approved, signed off and published Standard Operating Procedures

Create and maintain clinical and non-clinical policies and procedures

Implement practical solutions that use the specialist and departmental systems and processes

Provide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisation

Identify problems and develop and propose solutions to present to appropriate leader or stakeholders

Ensure day to day operational support required from area of specialisation is provided to enhance performance

Cost containment:

Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisation

Continuously review cost / benefit and Return on Investment within area of specialisation Drive customer-centricity:

Maintain a high level of impact on other departments to support improved delivery

Continually increase understanding of client and stakeholder needs, satisfaction and service delivery

Knowledge management:

Set up and maintain document library

Coach internal resources on new Standard Operating Procedures

Ensure that adequate knowledge regarding specialisation is shared as required and maintained within the research library

Provide advice and / or training as required

Maintain, develop and implement specialist knowledge within the day to day operations of the organisation

Maintain expertise level:

Be a member of related professional bodies

Ensure CPD (continual professional development) or similar accreditation requirements

are met annually to ensure maintained specialist accreditation

Network key relationships:

Engage with and provide support to the established network of internal and external expert resources and partners

Specialist support to projects:

Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when required

Conform to project management disciplines when participating in projects

Represent department or project on appropriate committees related to area of specialisation

Position Specific Outputs

Communication with third parties

Approval of all GEMS radiology cases, radiology experience would be advantageous

Review and reassign cases to the correct email or UMS boxes

Compile and maintain weekly statistics.

Daily communication to Business unit Managers, Team leaders - MA availability / Late cover / TAT.

Arrange and/or coordinate second opinions

Obtain discounted quotes

Obtain clinical information by contacting Member/Providers.

Review and refer escalations to Medical advisors

Refer to Medical advisors if MA clinical input is required.

Review cases referred to Medical advisors within our scope of practice according to policies and Scheme rules. Support the Medical advisors and team with any administrative functions where required.

Competency Requirements

Attribute:

Influence

Entrepreneurship

Credibility

Ownership

Collaboration

Knowledge:

Knowledge and understanding of scheme rules

and products

Knowledge of Quality Assurance methodologies

Knowledge of policies and procedures

Skill:

Numerical Ability

Data modelling and evaluation

Attention to Accuracy and Detail

Knowledge and application of relevant legislation

Relevant systems knowledge and application

Problem solving and decision making skills

Computer Technology Skills

Task Management

Executive Business Writing Skills

Adobe Creative Suite

Customer Focus

Communication Skills