Job Description
Position Purpose : To manage the spending of member funds by means of clinical interventions and managed care protocols.
Experience: At least 3 years general medical and surgical nursing experience in the private sector. ICU training and/or at least 1 year ICU nursing experience and 1 year hospital case management experience will be advantageous. In conjunction with above, at least 18 months hospital pre-authorisation experience.
Qualifications: Professional Registered Nurse with valid up to date registration with the South African Nursing Council (MANDATORY REQUIREMENT) KEY PERFORMANCE AREAS
Member Assessment and Care Coordination Review member medical records, treatment plans, and claims to assess care needs. Coordinate care with healthcare providers, including doctors, hospitals, and allied health professionals. Develop and implement individualised care plans for members with chronic conditions, complex medical needs, or high-cost cases.
Clinical Review and Authorisat...