Key Purpose:
The Clinical Coordinator will work closely with the Clinical and Admin members of the international team to ensure alignment of activities as well as the achievement of client service level objectives. He/ she is also responsible for the management of all pre-authorisation and medical assistance requests for international health insurance members. He/ she will liaise with the Client’s services contact centre, service providers and other members of the multi-disciplinary team to ensure the best outcome for all members.
Key Outputs:
Duties and Responsibilities included but not limited for all MSO Companies and subsidiaries:
- Align clinical activities to the Strategic objectives of the Business Unit.
- Work closely with team members and all stakeholders to ensure alignment of activities with client SLA objectives. Manage the entire spectrum of activities from pre-authorization, case coordination, clinical review through to discharge planning, chronic disease management and/or repatriation.
- Work shifts and hours as specified by operational requirements. Flexibility is essential.
- Ensure that call centre service levels are met:
i. all ACD calls to be answered in less than 3 rings (under 20 seconds)
ii. manage call talk time/ duration to an average of 180 seconds (3 minutes)
- Accept pre-authorisation requests telephonically, e-mail/fax:
i. verify membership validity
ii. verify benefit available for treatment requested as per scheme/ Insurers benefit rules.
- Assess medical necessity of treatment, appropriateness of facility, service provider and level of care, refer to medical protocols, and consult with Clinical Manager /Medical Advisor as required or if uncertain.
- Approve /decline request and communicate appropriately with member/ service provider and Update cases based on utilisation review and clinical updates from hospital.
- Attend to daily tasks as delegated, i.e. mail-box, daily pending status reports and liaise with scheme contact people on funding decisions as required.
- Provide detailed feedback within the prescribed SLA time frame to clients.
- Co-ordinate on-site/telecom Case management visits as may be required from time-time to monitor, level of care, utilisation review, discharge planning / negotiation with hospital admin/ Treating Specialists.
- Provide detailed feedback within the prescribed SLA time frame to management.
- Liaise with clients and service providers as required and participate in delegated projects.
Competencies:
Core Competencies & Inherent Requirements
Knowledge, Skills and Attitude
- Sound knowledge Customer Service
- Good knowledge of Industry legislation and funding guidelines
- Knowledge of Medical Fund/ Health Insurance and healthcare risk management
- Clinical Knowledge a must
- Initiate and implement processes
- Good communication skills, verbal and written
- Computer Literacy
- Critical evaluation of information
- Sound clinical decision-making ability
- Participating in protocol and process development
- Helpful, friendly and accommodating with a customer focused attitude
- Problem Solving and Output driven
- Self-Motivated and Assertiveness
- Ability to apply knowledge of Legislation to day-to-day work
- Liaison, coordination and consulting skills
- Patience, resilience and integrity
- Flexible and adaptable
Education and Experience:
Education
- · A minimum requirement of Grade 12
- · Ambulance Emergency Assistance (ILS), Emergency Care Technician, Critical Care Assistance
Experience
- Ambulance Emergency Assistance (ILS), Emergency Care Technician, Critical Care Assistance
- 2 years’ call centre experience advantageous
- 2-year pre - hospital road operations experience
- Clinical experience in-hospital environment advantageous
- Aeromedical knowledge advantageous
- Ability to function in a fast-moving high-pressure environment
- Experience with healthcare insurance risk management
- Experience with healthcare insurance
- Risk management principles an advantage
Work Location: In person
