Talent Pool: Clinical Consultant MMH251111-1

Role PurposeTo ensure the implementation of best practices and optimal medical care for members through expert clinical guidance, collaboration with healthcare professionals, and continuous improvement initiatives.RequirementsQualificationsNursing Diploma or Degree is EssentialRegistered with SANC (South African Nursing Council) is EssentialExperience3 - 5 years of experience as a registered nurse practitioner or equivalent experience.3 - 5 years of experience within the healthcare industry.2 - 3 years of experience within the managed care environment and/or healthcare consulting industry would be advantageous.KnowledgeIn-depth knowledge of evidence-based clinical guidelines, protocols, and best practices.Comprehensive knowledge of common medical conditions, diseases, and treatment modalities.Familiarity with the healthcare system and regulations in South Africa, including knowledge of relevant laws, policies, and regulatory bodies governing healthcare delivery, patient rights, and ethical standards.Understanding of quality improvement methodologies, patient safety principles, and tools for monitoring and improving healthcare outcomes.Knowledge of adverse event reporting, risk management, and quality assurance processes is important.Knowledge in utilising health information systems, electronic health records (EHRs), and other healthcare technologiesUnderstanding of ethical principles and ethical decision-making in healthcare, including patient confidentiality, informed consent, and end-of-life care.Familiarity with research methodologies, critical appraisal of research studies, and the ability to apply evidence-based practice in clinical decision-making.Awareness and understanding of cultural diversity, sensitivity to cultural differences, and the ability to provide culturally competent care to patients from diverse backgrounds.Understanding how clinical guidelines and protocols intersect with scheme rules and regulations.Familiarity with the guidelines and regulations governing prescribed minimum benefits.Duties and ResponsibilitiesPROCESSMeet the daily key performance indicator for proactive communication with members, ensuring timely assistance and effectively meeting their needs.Optimize bin management turn-around time, streamlining the process for prompt issue resolution and improving operational efficiency, in accordance with key performance indicator specifications.Implement policies and protocols related to scheme benefits to ensure consistent application and adherence, resulting in improved clarity and member satisfaction.Ensure appropriate control of benefits in and out of the hospital by closely monitoring utilisation, resulting in cost-effective care while maintaining quality outcomes.Apply exclusions correctly and consistently based on policy guidelines and regulatory requirements, ensuring fairness and accuracy in benefit coverage determinations.CLIENTMaintain quality customer service by promptly addressing members' inquiries and concerns, resulting in enhanced member satisfaction and trust.Build and maintain positive relationships with relevant stakeholders (e.g., hospitals and providers), fostering effective collaboration and ensuring seamless coordination of care for members.PEOPLEAppropriately refer cases to the case management team, ensuring members receive comprehensive care coordination, resulting in improved health outcomes and member satisfaction.Collaborate with the case management team, leveraging clinical expertise to support and enhance their decision-making process, leading to optimal care plans and member well-being.FINANCEMonitor and manage healthcare utilisation and costs, optimising resource allocation and maintaining financial sustainability while ensuring high-quality care.Identify cost-saving opportunities and process improvements, contributing to improved financial efficiency and organisational effectiveness.-346021296