Hospital Benefit Specialist PE

Discovery Limited; Gqeberha; On-site; ZAR 250,000 - 350,000; Full time

Job summary

A leading company seeks a registered nurse to assess patient cases and manage healthcare funding approvals. The role requires strong clinical experience in private hospital settings, effective communication skills, and the ability to handle case evaluations. An ideal candidate will demonstrate accountability, interpersonal skills, and a strategic mindset in the healthcare industry.

Qualifications

• Must have 3 years of clinical experience in a private hospital setting.
• 2 years managed health care experience preferred.
• ICU, Trauma/Casualty experience advantageous.

Responsibilities

• Assess cases based on members' clinical history and appropriateness of care.
• Manage treatment approvals and alternative discharge planning.
• Communicate effectively with all stakeholders regarding case updates.

Skills

Interpersonal savvy

Action oriented

Accountability

Planning and aligning

Courage

Tech savvy

Education

Matric

Registered Nurse

Valid SANC Registration

Tools

Microsoft Office

Job description

Job Location : Eastern Cape, Port Elizabeth Deadline : June 20, 2025 Quick Recommended Links

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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
• 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

The successful candidate must demonstrate the following competencies :

Role Specific Behaviours

• Ensures accountability.
• Action oriented
• Attracts top talent.
• Business insight
• Manages complexity.
• Manages conflict.
• Courage
• Directs work.
• Global perspective
• Cultivates innovation.
• Interpersonal savvy
• Builds networks.
• Nimble learning
• Organizational savvy
• Plans and aligns.
• Drives results
• Demonstrates self-awareness.
• Self-development
• Situational adaptability
• Balances stakeholders
• Strategic mindset
• 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)

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

Personal Attributes or Competency Profile

The Discovery Person

• Values Driven
• Learns on the Fly
• Resilient
• Instils Trust
• People Savvy
• Drives Results
• Medical / Healthcare jobs

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