Hospital Benefit Specialist

Discovery Limited; Sandton; On-site; ZAR 400 000 - 600 000; Full time

Job summary

A health insurance company is looking for a Hospital Benefit Specialist in Gauteng. The role involves assessing clinical cases, managing member benefits effectively, and ensuring communication with various stakeholders. Ideal candidates must be registered nurses with at least 3 years of clinical experience in a private hospital setting. The position emphasizes strong communication, problem-solving skills, and the ability to handle complex clinical queries.

Qualifications

• Registered Nurse with valid SANC registration required.
• 3 years clinical experience in a private hospital preferred.
• Travel up to 50KM may be required.

Responsibilities

• Assess clinical cases and manage members' benefits.
• Communicate effectively with stakeholders regarding case updates.
• Attend to patients on a daily report.

Skills

Effective Communication Skills (Verbal & Written)

Collaborates

Customer focus

Problem Solver

Education

Registered Nurse

Matric

Tools

Microsoft Office (Excel)

Job description

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

• 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 SOPs and Process experience (internal only)
• Provider payment arrangements (internal Only)
• Clinical coding knowledge of ICD-10 and/or CCSA

Personal Attributes or Competency Profile

The Discovery Person

• Values Driven
• Optimistic
• Learns on the Fly
• Resilient
• Instils Trust
• People Savvy
• Drives Results
• Problem Solver

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.