Registered Nurse - National Risk Managers

A Medical Insurance Company based in Benoni is looking for a Registered Nurse who will consult with members via relevant platforms to diagnosis and provide treatment plans for members according to Primary Healthcare Guidelines. Ensuring best clinical practice and quality is always provided to members. Handling of calls within Service level agreements.

Key Performance Areas

• Determine appropriate treatment once diagnosed.
• Perform administrative duties.

Key Tasks

Determine appropriate treatment once diagnosed.

• Establish the member’s primary diagnosis based on signs and symptoms.
• Identify the most appropriate treatment plan according to Clinical Guidelines for the member.
• Communicate correct benefits and Product knowledge.
• Evaluation of first-time resolution of members' calls.
• Action cases sent to the Medical Consultant within the SLA
• Encourage appropriate OTC utilization.
• Encourage appropriate Acute Medication Benefit utilization.
• Deliver appropriate information to healthcare users.
• Educate members of potential side effects to medication
• Provide members with information and advice on prescribed over-the-counter medication.

Perform administrative duties.

• Improve areas identified by the QA
• Continue with ongoing Learning and Development to stay abreast with healthcare industry
• Capture of accurate clinical records on system
• Provide effective communication to encourage and maintain behavioural
• Script to schedule 4, when clinically appropriate
• Issue Sick notes when clinically appropriate
• Adhere to time and

Secondary Tasks / Activities

• Prioritize incoming authorization requests and/or queries according to urgency.
• Assess pre-authorisation requests for GP visits, specialist visits, emergency room visits, diagnostic procedures, hospitalisation for illness and accident events, including the appropriate facilities (day clinics, sub-acute facilities, home nursing and preferred providers)
• To check the reasons for authorisation and documentation received are appropriate and confirm if it according to set protocols, guidelines, formularies, and preferred provider agreements. Based on protocols approved or decline. If the reason for authorisation is not defined in the protocols or guidelines escalate the case for clinical review
• Approve or decline benefits accurately according to the benefits per benefit option and strictly according to the protocols.

Other requirements

• Registered with SANC
• Call Centre experience
• Dispensing Certificate

Essential Qualifications

• Matric
• Nursing Diploma/Degree

• Dispensing Certificate

Essential Experience

• Experience in clinical evaluation of patient’s signs and symptoms
• IT system navigation

Desirable Experience

• Primary Healthcare
• Call Centre experience
• Dispensing Certificate
• Experience in issuing of scripts as per regulation
• Experience in issuing of sick notes as per regulation

Knowledge and Skills

• Extensive MS Office knowledge
• Strong written and verbal communication skills
• Good telephonic etiquette
• Good listening skills
• Strong administration skills
• Knowledge in Primary Healthcare
• Strong organisation skills
• Good time management skills

Attributes

• Holistic thinker
• Critical thinker
• Able to work under pressure
• Team player
• Compassionate
• Honest, hardworking, and humble