Hospital Benefit Specialist - KZN

Medical Aid, Bank, Insurance, Invest & Vitality; Durban; On-site; ZAR 200 000 - 300 000; Full time

Job summary

A health organization based in Durban is seeking a Hospital Benefit Specialist to manage clinical cases and ensure appropriate member care. The ideal candidate must be a Registered Nurse with experience in a private hospital setting and strong communication skills. This full-time role offers the chance to make a significant impact within the healthcare system.

Qualifications

• 3 years clinical experience in a private hospital setting.
• 2 years managed health care experience.
• Valid driver's licence and own transport.

Responsibilities

• Assess clinical case in relation to member's history and benefit structure.
• Effective communication to stakeholders regarding care and funding decisions.
• Handle escalations from Providers and internal stakeholders.

Skills

Effective communication skills

Active listening skills

Customer focus

Financial acumen

Education

Must be a Registered Nurse

Matric

Valid SANC registration

Tools

Microsoft Office (Excel)

Job description

Hospital Benefit Specialist

About Discovery

Discoverys 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 :

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 :

• 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

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 licence and own transport (working hours 08:30‑17:00 & travel up to 50km may be required)

Effective communication skills (verbal & written)

Telephone etiquette

Active listening skills

Advantages

• 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

• 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.

Employment Type

Full time

Vacancy

1