Clinical Governance Researcher

at  Health Solutions

INTRODUCTION

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.

REQUIREMENTS

• Matric
• Nursing Qualification (Enrolled / Registered nurse)
• Minimum of 5 years Clinical experience
• Registered with the SANC
• Minimum 3 years medical aid industry knowledge
• Pharmacology knowledge
• Computer literate and competent in Word / Excel
• Knowledge of Oracle system (workflow, association of documents) an advantage
• Good understanding of the medical scheme rules and regulations including
• Knowledge of new medical technology
• Basic understanding of legislation relating to PMB and its application
• Good Written and oral communication skills

ROLE PURPOSE

Ensure that stakeholders are given the correct information within the Clinical Governance function.

DUTIES & RESPONSIBILITIES

• Manage all complex clinical cases and requests for additional information from providers and members.
• Research all data available regarding a request / appeal.
• To be able to make a clinically appropriate decision pertaining to letter of motivation from providers.
• Dealing with member and doctor queries.
• Document decisions (update Workflow).
• Telephonic resolution of queries where applicable.
• Answering queries referred by Contact Centre, Pre-Authorisation, Scheme office and fund management, members and providers.
• Producing stats and reports required by the schemes.