Talent Pool: Wellness Coach MMH

Role Purpose

The purpose of this role is to manage quality and cost of clinical and medical care by liaising with members and providers.

Qualifications

• Registered or Enrolled Nurse or Counsellor - Essential
• A Registered Nurse with the South African Nursing Council (SANC) - Essential
• Health Coaching certification - Advantageous

• Minimum of 5 years working experience within Managed care experience - Essential
• 3 years clinical practice as the registered nurse in the clinical setting is essential.
• Training as Primary Care Nurse Practitioner will be an advantage.
• Experience in both HRM and DRM will be an advantage.
• Experience as a home based case nurse be an advantage.
• Experience in community health centre base nursing care will be an advantage.
• Experience as a registered nurse in a GP practice will be an advantage.

• Must have advanced Excel skill
• Knowledge of prescribed minimum benefits basic principles.
• Knowledge of managed care principles.
• Knowledge of protocols and treatment plans.
• Knowledge of pathology analysis.
• Knowledge of the CDL conditions and the ICD
  10 codes.
• Knowledge of preventative health benefits to better manage the health risks.
• Knowledge of clinical guidelines and policies.
• Knowledge of acute and chronic diseases, prevention, causes, treatment of diseases.
• Knowledge of anatomy and physiology.

• Prioritise work in accordance with required intensity of patient management.
• Daily planning and organisation in accordance with allocated member.
• Accountability for daily work load and required interventions.
• Interaction with Patient, GP and Specialist and other providers including home based and convalescent nurses.
• Manage quality and cost of clinical and medical care by liaising with members and providers and manage the reduction of recurring costly events and medicine spend.
• Work with individual consumers (beneficiaries and providers) of the scheme to achieve better health outcomes while helping beneficiaries to understand their disease(s) or health status.
• Reduce the downstream clinical and financial risk associated with the beneficiary.
• Co-ordinate the required interactions between the various providers and hospitalist.
• Keep detailed records of patient interaction and follow ups done by updating system records.
• Ensure the effective, accurate and timeous completion of relevant documentation accompanying transactions.
• Continued Medical Education task.
• Manage cost of an in or out-patient episode by implementing appropriate policies and guidelines.
• Arrange post hospital care where necessary.
• Authorise appropriate and cost effective medical care and treatment.
• Ensure the consistent and correct application of exclusions.
• Adhere to policies and procedures and take corrective action where necessary.
• Adhere to organisational best practice and legislative requirements.
• Ensure accurate application of acute case management protocols.

• Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.
• Provide regular reports on delivery of services against agreed service level agreements and in terms of overall client targets.
• Provide authoritative, expertise and advice to clients and stakeholders.
• Build and maintain relationships with clients and internal and external stakeholders.
• Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments.
• Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed.
• Make recommendations to improve client service and fair treatment of clients within area of responsibility.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.

• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.