DRIDIE MUKONDELELI

Work in the MRT workflow pools

• Clinical claims pool
• Claims with shortfalls relating to the use of a non dsp facility or provider
• The use of an additional doctor or codes (review the appropriateness during that event)
• Complex cases pool
• Case that are off protocol and needs discussion in a clinical review meeting
• Gathering of clinical evidence and make recommendations for funding decisions based on previous similar cases and recent evidence
• Preparing cases, case presentations and loading member remarks and clinical exceptions
• Communicating funding decision to the relevant parties
• Prescribed minimum benefit pool
• Reviewing escalated PMB appeals from members & providers and making appropriate funding decisions by applying PMB protocols
• Apply government stipulations in terms of PMB’s and treatment algorithms
• Communication to external and internal parties surrounding PMB decision outcomes
• Continuously updating your own knowledge relating to DH and In-House products
• Make concise clinical decisions according to the MRT guidelines and processes
• Request and review ICD /procedure codes. Photographs. Motivation letters and further supporting documents as required
• Escalating cases /queries that cannot be resolved to senior MRT consultant /medical advisors /clinical manager
• Manage the Dr-to-Dr queue. Resolve queries first time before escalating to medical advisors when request come through
• Decision making support to the pre-authorization call center , clinical CRM, PMB specialist, claims department, Hospital benefit specialists and Casemanager
• Telephonic and written communication with doctors, Providers and members (inbound /outbound)
• Understand of IQS and compliancy in ensuring IQS objectives are met

• All calls answered according to set standards
• Transfer calls only when no further assistance can be rendered
• Maintain accurate details of pre authorisation information
• Confirm scans according to set protocols
• Check validity membership
• Ensure that the reason for admission is appropriate
• Request BHF /ICD and CPT and motivation letters on pre authorisation
• When necessary offer transfer for members who need more medical information about medical procedures
• Follow-up urgent queries capture messages on the system
• Give authorization number for cases that are already loaded
• Provide product information to all clients in line with standard and protocols of the call centre maintain confidentiality
• Report writing 100%
• Reviewing records 100%
• Conducting risks assessments 100%
• Time management skills 80%
• Problem resolution 80%
• Positive learning process 80%
• Communication 80%
• Results oriented 80%
• Excellent communication 80%
• Computer literate 80%
• Reports generation and analysis 80%

• Perform clinic sister duties according to industry regulations and industry best
• Manage the average feet-per-hour rate and set clinic objectives to enhance patient
• Ensure all clinic services are available at the clinic
• Keep accurate records of patient details
• And ensure communication is followed up
• Ensure that the clinic is open and operational according to the hours stated in the operational
• Process claim accurately and timeosly according to industry
• Ensure stock is sufficient in the clinic according to the business
• Build and maintain healthy relationships with following stakeholders: patients store dispensery manager
• Colleagues
• Medical aids
• Suppliers/Reps key role players in the community
• And other healthcare

• Similar to the job specification at Dischem

• Monitoring women's health during their pregnancies
• Helping to develop and support a women's birth plan
• Undertaking clinical examinations and screening as part of antenatal care
• Carrying out screening tests and taking blood samples and temperature
• Identifying high risk pregnancies
• Administering drug on exemption
• Running parenting classes as part of antenatal care
• Assisting with care and monitoring during labor and birth
• Providing advice and support to the of newborns.for example teaching new and expectant mothers hoe to feed their babies
• Providing advice and support to parents coping with miscarriage
• Stillbirth, termination and neonatal death
• Performing emergency procedures and referring women to other medical staff where necessary
• Writing reports and documenting assessments and care