Ensure that stakeholders are given the correct information within the Clinical Governance function.
Requirements
- Matric
- Minimum of 5 years Clinical experience or in operations clinical area
- Minimum 3 years medical aid industry knowledge
- Pharmacology knowledge
- Computer literate and competent in Word / Excel
- Knowledge of Oracle system (workflow, association of documents) an advantage
- Good understanding of the medical scheme rules and regulations including PMB
- Knowledge of new medical technology
- Manage all complex clinical cases and requests for additional information from providers and members
- Research all data available regarding a request / appeal
- To be able to make a clinically appropriate decision pertaining to letter of motivation from providers
- Dealing with member and doctor queries
- Document decisions (update Workflow)
- Telephonic resolution of queries where applicable
- Answering queries referred by Contact Centre, Pre-Authorisation, Scheme office and fund management, members and providers.
- Producing stats and reports required by the schemes
