Medical Scheme jobs in Highveld, Gauteng

Introduction

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

Disclaimer

As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose

To ensure the implementation of best practices and optimal medical care for members through expert clinical guidance, collaboration with healthcare professionals, and continuous improvement initiatives.

Requirements

Duties & Responsibilities

• Meet 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.

CLIENT

• Maintain 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.

PEOPLE

• Appropriately 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.

FINANCE

• Monitor 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.

Competencies