Jobs

Case Manager – Medical Aid – R25 to R31 000.00 CTC- Bryanston

New and exciting vacancy available at this forward thinking and dynamic medical aid organisation based in Bryanston. Seeking the services of an experienced and dedicated case manager. Good personal attributes would be well organised, hardworking, and an ability to absorb pressure. Excellent future career prospects and opportunity for growth both personally and professionally.

Scope of responsibility:

  • Overall responsibility for incoming calls from Hospitals Case Managers relating to authorizations for procedures in Hospitals, Casualty, GP or Dental providers rooms.
  • Hospital case management from the issuing a guarantee of payment (GOP) to final discharge and any follow up treatment where required.
  • All medicines related issues for special cases and off formulary items
  • Monitor hospital and provider abuse
  • Ensure that all calls and cases are fully and clearly recorded on the MIP system accordingly.
  • Ensure efficient Customer Service and compliance to agreed SLA’s
  • Follow up with GP providers who may be over utilizing the “in rooms” procedures.
  • Manage and maintain data integrity and update accordingly where necessary
  • Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained
  • Regularly review all approved claims and ensure that all are settled according to correct tariffs and procedures
  • Supply all monthly management reports
  • Any other duties as assigned by your supervisor from time to time

 

Previous qualifications skills and experience:

  • Matric
  • Registered Nursing diploma
  • Valid membership of SANC
  • At a minimum of at least 3-4 years’ experience in a similar role
  • MIP Application System experience would be an advantage.
  • Sound understanding of the South African Health Industry, benefits and options etc.
  • ICD codes, modifiers and RPL tariff knowledge and understanding
  • Ability to liaise with external parties – clinicians and members
  • Ability to work within an established team
  • Excellent oral and written communication skills
  • Customer centric attitude
  • Excellent analytical skills and pays attention to detail
  • Computer literate - MS Office suite, i.e. Word, Excel
  • A good understanding of claims risk profiling
  • Experience in claims auditing

 Clear criminal record, ITC and contactable previous employment references are essential. Please mail a comprehensive CV to This email address is being protected from spambots. You need JavaScript enabled to view it.

 


 

Provider Network Consultant – Medical Aid – R24 to R31 000.00 CTC- Cape Town  

New and exciting vacancy available at this forward thinking and dynamic medical aid organisation based in Cape Town. Seeking the services of a professional and dedicated provider network consultant. Well spoken, organised and reliable. Excellent career prospects and opportunity for growth both personally and professionally.

Scope of responsibility:

§  Develop integrated networks with quality providers yielding a geographical competitive, broadly accessible, stable network that achieves company objectives.

§  Evaluate practices in analysing member care, trend quality compliance at provider level.

§  Develop action plans and programs to support provider practices in continuous quality improvement using approved guidelines.

§  Responsible for provider education, contract compliance, and resolving provider concerns and issues

§  Negotiate all Provider Network, casualty and Hospital contracts on an individual basis and or groups

o   (IPA’s and discipline specific groups) where appropriate.

§  Partner with internal stakeholders to create a seamless experience for providers.

  • Ensure all enquiries are resolved satisfactorily and customer requirements within business rules

§  Do continuous risk management of all providers and take action in areas where costs are exuberant

  • Identifies and resolves network access gaps or perceived gaps.
  • Supply monthly management reports
  • Must be able to travel to all providers
  • This position requires extensive travelling.

 

 

Previous qualifications skills and experience:

  • Matric.
  • At least 4-5 years’ experience in a similar role
  • Sound understanding of the South African Health industry, options and benefits etc.
  • Ability to develop interpersonal business relationships with network providers and internal business partners leading to high provider and member satisfaction.
  • Meeting targets and regulatory requirements.
  • Must have experience in working with all provider types and understand how providers administration systems work in order for claims to be submitted.
  • Must have a working knowledge of behavioural health provider business operations and analytical abilities to resolve provider issues.
  • Excellent oral and written communication skills
  • Computer literate - MS Office suite, i.e. Word and Excel a must
  • A good understanding of claims risk profiling
  • Own reliable transport and valid drivers licence

Clear criminal record, ITC and contactable previous employment references are essential. Please mail a comprehensive CV to This email address is being protected from spambots. You need JavaScript enabled to view it.


Provider Network Consultant – Medical Aid – R24 to R31 000.00 CTC - Durban  

New and exciting vacancy available at this forward thinking and dynamic medical aid organisation based in Durban.  Seeking the services of a professional and dedicated provider network consultant. Well spoken, organised and reliable. Excellent career prospects and opportunity for growth both personally and professionally.

Scope of responsibility:

§  Develop integrated networks with quality providers yielding a geographical competitive, broadly accessible, stable network that achieves company objectives.

§  Evaluate practices in analysing member care, trend quality compliance at provider level.

§  Develop action plans and programs to support provider practices in continuous quality improvement using approved guidelines.

§  Responsible for provider education, contract compliance, and resolving provider concerns and issues

§  Negotiate all Provider Network, casualty and Hospital contracts on an individual basis and or groups

o   (IPA’s and discipline specific groups) where appropriate.

§  Partner with internal stakeholders to create a seamless experience for providers.

  • Ensure all enquiries are resolved satisfactorily and customer requirements within business rules

§  Do continuous risk management of all providers and take action in areas where costs are exuberant

  • Identifies and resolves network access gaps or perceived gaps.
  • Supply monthly management reports
  • Must be able to travel to all providers
  • This position requires extensive travelling.

 

 

Previous qualifications skills and experience:

  • Matric.
  • At least 4-5 years’ experience in a similar role
  • Sound understanding of the South African Health industry, options and benefits etc.
  • Ability to develop interpersonal business relationships with network providers and internal business partners leading to high provider and member satisfaction.
  • Meeting targets and regulatory requirements.
  • Must have experience in working with all provider types and understand how providers administration systems work in order for claims to be submitted.
  • Must have a working knowledge of behavioural health provider business operations and analytical abilities to resolve provider issues.
  • Excellent oral and written communication skills
  • Computer literate - MS Office suite, i.e. Word and Excel a must
  • A good understanding of claims risk profiling
  • Own reliable transport and valid drivers licence 

 

Clear criminal record, ITC and contactable previous employment references are essential. Please mail a comprehensive CV to This email address is being protected from spambots. You need JavaScript enabled to view it.


 

 

free joomla template
template JoomSpirit