Hospital Benefits Specialists

Job Description

Hospital Benefits Specialist – Gauteng

About Discovery

Discovery’s core purpose is to improve people’s health and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose and whose values ​​align with Discovery’s. Our fast-paced, dynamic environment enables smart, proactive people to reach their full potential.

As global thought leaders, we at Discovery are passionate about innovating not only to achieve financial success but also to drive positive and meaningful change in our society.

About Discovery Care

Discovery Care, a subsidiary of Discovery Health, comprises several specialized clinical areas with segmented teams. The Chronic Disease and Prescribed Minimum Benefit (PMB) Management team handles PMB and Chronic Disease claims and manages complex clinical consultations. The HIV/Oncology and Hospital Case Management teams review clinical cases specific to their areas of expertise.

The Personalized Care Team

Provides practical services and resolves complex inquiries in sensitive cases. Additionally, Hospital Benefits Specialists, as part of the field team, are responsible for real-time risk management, and the Care Coordination Service administers Managed Care programs.

Main Objective: The selected candidate will be responsible for, among other duties, the following:

Evaluating the case in relation to the following:

• Member’s medical history
• Member’s benefits structure
• Clinical information and coding provided
• Level of care provided
• Facility suitability
• Attending physician suitability
• Treatment suitability
• Managing the member’s benefit and the corresponding plan risk through a thorough process to approve or deny funding and ensure the member receives the appropriate level of care.
• Planning discharge, offering the member alternatives for receiving treatment (including home hospitalization, home care, etc.).

Effective and accurate communication with all stakeholders

• Case updates to the provider
• Funding decisions and confirmation of benefits to members
• Requesting additional information from the attending physician or clinic manager
• Collaboration with the patient services manager and hospital staff
• Management of escalations from providers and internal stakeholders
• Preparation and presentation of complex cases for clinical review
• Analysis of inefficiencies and proposals for corrective action
• Appropriate internal referral of cases for clinical management

Operational Objectives

• Patient care in the daily report
• Review of all low-complexity admission requests
• Quality of processes

Competencies: The selected candidate must demonstrate the following competencies:

Job-Specific Behaviors

☒ Ensures accountability.

☒ Action-oriented

☐ Manages ambiguity.

☐ Attracts top talent.

☐ Business acumen

☐ Collaboration

☒ Effective communication

☐ Complexity management

☐ Conflict resolution

☐ Courage

☒ Customer focus

☒ Sound decision-making

☐ Talent development

☐ Values ​​diversity

☐ Team leadership

☐ Drives engagement

☐ Financial acumen

☐ Global perspective

☒ Fosters innovation

☐ Interpersonal skills

☐ Networking

☐ Agile Learning

☐ Organizational Skills

☐ Persuasiveness

☐ Planning and Alignment

☒ Resilience

☐ Resourcefulness

☒ Results Orientation

☐ Self-Awareness

☐ Self-Development

☐ Situational Adaptability

☐ Stakeholder Relationship Management

☐ Strategic Vision

☐ Building Effective Teams

☐ Technological Proficiency

☐ Building Trust

☒ Drives Vision and Purpose

☒ Optimizes Work Processes

Education and Experience. The following requirements are essential:

• High School Diploma
• Registered Nurse
• Valid registration with the SANC (South African Nursing Council)
• 3 years of clinical experience in a private hospital (ICU, Emergency/Trauma, or General Medicine ward preferred)
• 2 years of experience in managed care
• Proficiency in Microsoft Office (especially Excel)
• Valid driver’s license and own vehicle (working hours are 8:30 a.m. to 5:00 p.m. and travel up to 50 km may be required)
• Effective communication skills (oral and written)
• Telephone etiquette
• Active listening skills

The following qualifications are advantageous:

• 1-2 years of ICU experience
• Knowledge of Department of Health Standard Operating Procedures (SOPs) and process experience (for internal staff only)
• Payment arrangements with providers (for internal staff only)
• Knowledge of ICD-10 clinical coding and/or CCSA

Personal Attributes or Competency Profile: The Ideal Candidate

• Values-oriented
• Optimistic
• Quick learner
• Resilient
• Trustworthy
• Interpersonal skills
• Results-driven
• Problem solver

EQUAL EMPLOYMENT OPPORTUNITIES The Company’s approved Equal Employment Opportunities Plan and Objectives will be taken into account in the selection process. As an equal opportunity employer, we encourage and welcome applications from people with disabilities.