Disease Management Coach

Medshield Medical Scheme

Gauteng, South Africa


Aug 17

Responsible for the analyses, developing, and implementing of multifaceted risk management interventions on chronic patient-specific cases telephonically utilizing their clinical, disease and case management skills, to prevent or reduce the Schemes medical exposure. -Contacting of members and building of positive relationships with the members to achieve positive outcomes.-Analyze and interpret reports, clinical results, and patient history information to provide an action plan per patient.Engage with the third-party Managed Care Partners and Medical Providers to facilitate registration on the appropriate programs and authorization of care baskets.-Ensure adherence to care plans by encouraging members to consult regularly with their Doctors and have their regular special investigation.-Ensure adherence to Scheme Rules on all authorizations and clinical updates where applicable.-Communicate with members and service providers to address disease management matters.-Assist with Health Risk Management Monitoring & Management of hospital re-admissions-Compile & submit detailed reports to the Scheme on costs and patients progress-Educate members on their chronic conditions via email or telephonically.-Support the Clinical Manager and HOD on any projects related to risk management.-Meet the required daily targets and daily operational delivery within the Clinical Risk Division according to set Service Level Agreements (SLAs) and the Performance Contract.-Develop and maintain a general clinical understanding of Tariff coding, ICD, CPT, SAMA, RPL and National Pharmaceutical Product Interface (NAPPI) codes, and how these affect clinical billing rules.-Assist with complaints, queries, and escalations-Monitor outputs and results to inform process efficiencies to achieve targets.-Accountable for adhering to and managing error rates according to the QA policy within the division.-Develop and maintain adequate knowledge of data handling and ensure proper record keeping of related records.-Contribute to the targeted research into local and international clinical guidelines and funding policies.-Participate in clinical projects/studies and interdisciplinary meetings as required.-Assist with special requests on any clinical decision-making when required.-Provide support in conducting year-end testing, and special projects when required.-Provide knowledge and expertise of prevailing legislation within the funding environment.-Assist in identifying and adhering to fraud controls, risk prevention principles, sound governance and compliance processes, and tools to identify and manage risks.-Support and provide evidence to all internal, external, and ISO audit requirements.-Maintain quality risk management standards in line with the requirements from ISO9001:2015.-Maintain and enforce all clinical risk-related Service Level Agreements to minimize business risk and ensure business continuity.-Review and amend all related Standard Operating Procedures in consultation with the Supervisor: Clinical Risk to ensure business optimization.-Adhere to all relevant laws, policies, and Standard Operating Procedures throughout the organization.-Treat information and documentation as private and confidential, and only disclose to any parties as according to the SOPs and relevant regulations.-Build and maintain effective internal and external stakeholder relationships for the purpose of expectations management, knowledge sharing, and integration.-Contacting members and building positive relationships with the members to achieve positive outcomes.-Convene and attend meetings and present findings to relevant stakeholders when required.-Liaise with members, brokers and healthcare professionals, and 3rd parties delivering exceptional customer service.-Provide educational information to relevant parties on health conditions, treatment, and patient care.-Provide input and support to the clinical committees, external advisory panel, and other committees as and when required.

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