Talent Pool: Wellness Coach MMH251111-11

Role PurposeThe purpose of this role is to manage quality and cost of clinical and medical care by liaising with members and providers.RequirementsQualificationsRegistered or Enrolled Nurse or Counsellor - EssentialA Registered Nurse with the South African Nursing Council (SANC) - EssentialHealth Coaching certification - AdvantageousExperienceMinimum of 5 years working experience within Managed care experience - Essential3 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 will 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.KnowledgeMust have advanced Excel skillKnowledge 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 ICD10 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.Duties and ResponsibilitiesPROCESSPrioritise 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.CLIENTContinuously 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 serviceManage 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.PEOPLEBuild 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.-346021296