Purpose of the Job
The Clinical Risk Management Nurse’s role is to reduce unnecessary and/or excessive use of healthcare providers by members that have been identified through claims analyses as high utilisers. The Risk Management nurse engages with the high utilising members/employees (and with their treating providers where indicated) to assess the reason for high utilisation, and to implement risk management interventions to reduce unnecessary/excessive utilisation.
- Line functionThe Clinical Risk Management Nurse reports to the Provider Network Manager.
- Staff function
The Risk Management Nurse has a staff function relationship with the following positions:
- Disease Management nurses
- Medical advisors
- Pharmacists and pharmacist assistants
- Client services staff
- Administrative staff
- Hospital Utilisation Management staff
Duties and responsibilities
- Establish or verify if the claims data is a true reflection of the member’s health-seeking behaviour.
- Establish the reasons for the high utilisation.
- Identify actions that can be taken by the member to reduce unnecessary utilisation.
- Educate the member on possible ways to meet their medical needs and reduce the high utilisation behaviour.
- Explain any limits that apply to the number of consultations that a member is entitled to and processes to be followed after such limits are reached.
- If necessary, contact the member’s treating doctor to discuss any concerns.
- Refer complex clinical cases to the medical advisor, DUR pharmacist or Disease Management nurse for further intervention or support.
Experience and Qualifications required
- Qualified as Enrolled or Registered Nurse.
- Experience and knowledge of the medical scheme environment or.
- Experience and knowledge doctors’ surgery.
- Experience in risk management in a medical scheme environment an advantage.
- Experience and knowledge of Network options or Risk Transfer arrangements an advantage.
- Ability to deal professionally with conflict situations or difficult people (members and/or providers).
- Be able to speak, write, read and comprehend fluently in English.
- Other languages: The ability to converse in a local black language e.g. Zulu, Xhosa, Sotho an advantage. The ability to converse in Afrikaans an advantage.
- Current and continued registration with the SA Nursing Council.
- Proficiency in the following programmes is required:
- MS Word
- MS Outlook/ email
- Ms Explorer/Internet
- The company is based in Sunninghill Park, Sandton.
- The hours of work: Office hours from Mon to Fri, 8am to 5pm.
- Confidentiality of all patients’ clinical information and conditions to be maintained and respected. The employee may be required to sign a confidentiality agreement.
- Company intellectual property and systems not be disclosed to external agent or organization.
The Employment Equity approach of Universal Healthcare broadly aims to:
- Foster diversity in the workplace;
- Promote equal opportunity and fair treatment in employment through the elimination of all forms of unfair discrimination.
Thank you for your interest in working for Universal Healthcare. Kindly note that your application will be reviewed in accordance to the job requirements and the Company will select suitable candidates with cognisance of its Employment Equity policy. Should no response be received within 30 working days from your date of submission, please consider your application unsuccessful for this position, your resume will remain active in our database should you be suitable for positions in future.
- Excellent communication skills – written and oral
- Excel Spreadsheets
- Report Writing
- Deadline driven
Employer & Job Benefits:
- Medical Aid
- Gap Cover
- Pension Fund
- Group Life and Permanent Health Insurance
- 360 Degrees Loyalty Programme
- Funeral Cover