Maureen Madlhophe
Pretoria
Summary
Dynamic Clinical Consultant with extensive experience in managed healthcare administration, excelling in disease risk management, and effective communication. Proven track record in optimizing hospital utilization and enhancing patient outcomes through strategic planning and negotiation skills. Adept at report writing, performance management, ensuring adherence to clinical guidelines, and achieving significant cost savings. Experienced in providing clinical consultation within diverse healthcare settings. Brings demonstrated knowledge of healthcare regulations, policy interpretation, and risk management strategies. Effectively collaborates with multidisciplinary teams to enhance patient outcomes and improve service delivery efficiency. Previous work has led to significant improvements in operational processes and overall care quality standards. Strong analytical skills, with the ability to identify and resolve complex clinical issues. Insightful Clinical Consultant known for high productivity and efficient task completion. Possess specialized skills in patient care management, healthcare regulation compliance, and clinical workflow optimization. Excel in communication, problem-solving, and adaptability, ensuring seamless integration of clinical strategies with organizational goals.
Overview
25
25
years of professional experience
Work History
Clinical Consultant
PPS HealthCare Administrators
Gauteng
05.2017 - Current
- Ensuring a successful and smooth disease risk and case management process.
- Ensure adherence to Scheme Rules on all disease risks and clinical updates.
- Receive, evaluate, adjudicate, authorize, and capture requests from members for disease risk requests, using telephone, system, rules of the scheme, and SOP to manage the hospital utilization by members in a cost-effective manner.
- Refer appeals to the Medical Advisor to make a final decision.
- Communicate with members, service providers, using telephone, fax machine, or MS Outlook to manage the disease risk process.
- Contacting members and building positive relationships with them to achieve positive outcomes.
- Analyze and interpret reports, clinical results, and patient history information to provide an action plan for each patient.
- Effective handling of internal and external clinical queries involves communicating with members and service providers to address disease management matters.
- Assist with health risk management, monitoring, and management of hospital readmissions.
- Educate members about their chronic conditions via email or telephone.
- Support the Service Manager, HOD, on any projects related to risk management.
- Ensuring a successful and smooth pre-authorization and case management process telephonically in a call center environment, via email, and through online chat.
- Ensure adherence to Scheme Rules on all hospital authorizations and clinical updates.
- Ensure the correct allocation of facilities for our members.
- The effective handling of internal and external clinical queries involves communicating with members and service providers to address hospital utilization matters.
- Assist with health risk management, monitoring, and management of hospital readmissions.
- Compile and submit detailed reports to the Scheme on high costs and patients' progress.
- Reason for leaving: Growth.
Clinical Claims Adjudicator
Rand Mutual Assurance
Gauteng
03.2015 - 04.2017
- To process Compensation for Occupational Injuries and Diseases
- To assess and validate claims submitted
- To adjudicate and process claims in terms of COIDA, RMA procedures and instructions
- To render medical support to internal and external stakeholders
- Medical case management of injured cases
- Hospital visits (on site visits)
- Education and physical Rehabilitation of the injured
- Home visits of the injured to see what needs to be adjusted post hospital discharge
- Administration of pensioner medical plan
- Medical management of severe injured claims
- Review and updating of ICD 10 codes and CPT codes
- Confirmation of the permanent disability claims with Medical Advisor
- Authorization of permanent disability awards within authority limits
- Reason for leaving: Growth
Oncology Unit Manager
Netcare Pretoria East Hospital
Gauteng
11.2014 - 02.2015
- Personnel management
- Unit Budget-Financial Planning and Management
- Strategic Planning of unit
- Running Quality Improvement Programs
- Infection control program
- Time management
- Performance monitoring and evaluation of subordinates
- Students’ accompaniment and evaluation as per their workbook
- Assessments of students on procedures/practical’s
- Liaising and communicating with the Medical Doctors, Service providers, Case managers
- Reports presentation of patients in writing and verbally
- Clinical Mentoring of Staff and students
- Counselling of patients and family with Oncology
- Conducting interviews for new posts and Orientation and Induction of new recruits
- Reason for leaving: Seeking Permanent employment
Clinical Consultant-Managed Health Care-Case Manager
Keyhealth Medical Aid
Gauteng
06.2011 - 10.2014
- Oncology case management, hospital case manager, wound care, and sub-acute manager.
- Hospital Risk Management.
- Pre-authorization of treatment: chemotherapy, radiotherapy.
- Liaison with oncology patients who are newly diagnosed.
- Liaison with the medical advisor/SAOC for treatment review.
- Oncology claims.
- Approve or deny treatment plans as per SAOC guidelines and clinical appropriateness.
- Liaising with service providers.
- Validate membership.
- Load the case using the correct ICD-10 codes.
- Generate savings, and document them on a spreadsheet as proof.
- Confirm oncology benefits before approving treatment.
- Update the hospital cases of members admitted.
- Negotiate alternate treatment or care for patients, e.g., hospice, step-down, or home nursing.
- Health promotion, health education, screening, and prevention advice.
- Authorize CT/MRI, and other radiology tests related to oncology.
- Reason for leaving: Growth and diversity.
Oncology Case Manager
Metropolitan Health Group
Gauteng
09.2008 - 04.2011
- Oncology case management
- Preauthorization of treatment-chemo, radiotherapy
- Liaison with oncology patients newly diagnosed
- Liaison with medical advisor/SAOC for treatment review
- Oncology claims
- Approve/deny treatment plans as per SAOC Guidelines and clinical appropriateness
- Liaison with service providers
- Validate membership
- Load case using correct ICD 10 Code
- Try to make savings and document them on spreadsheet as proof
- Confirm oncology benefits before approving treatment
- Update hospital cases of members admitted
- Negotiate alternate treatment/care for patients eg: Hospice, Stepdown or home nursing
- Health promotion health education screening and prevention advise
- Reason for leaving: to diversify and growth
Case Manager
Muelmed Mediclinic Hospital
Gauteng
05.2007 - 08.2008
- Pre-authorizations for hospital admissions and surgical procedures.
- ICD-10 and CPT coding.
- Clinical updates of inpatients.
- Monitoring high-cost cases.
- Arranging transfers to facilities, e.g., Sub Acute.
- Obtaining motivation letters from Drs.
- Hospital Risk Management
- Oncology and HIV/AIDS disease management.
- Use of reimbursement methods (BHF, FFS, Per Diems, PMB, CDL).
- Reason for leaving: Corporate opportunities and growth.
Unit Manager
Muelmed Mediclinic Hospital
Gauteng
01.2005 - 04.2007
- Personnel management
- Unit Budget-Financial Planning and Management
- Strategic Planning of unit
- Running Quality Improvement Programs
- Infection control program
- Time management
- Performance monitoring and evaluation of subordinates
- Students’ accompaniment and evaluation as per their workbook
- Assessments of students on procedures/practical’s
- Liaising and communicating with the Medical Doctors, Service providers, Case managers
- Reports presentation of patients in writing and verbally
- Clinical Mentoring of Staff and students
- Counselling of patients with Oncology and HIV/AIDS
- Reason for leaving: Moved from bed side nursing
Professional Nurse
Muelmed Mediclinic Hospital
Gauteng
09.2004 - 12.2004
- Comprehensive nursing care of Medical, Surgical, Gynae, Psychiatry and palliative patients
- Mentoring of students
- Participate in QIP Programs
- Medication administration
- Wound care and infection control
- Acting Unit Manager
- Reason for leaving: Got the post of Unit Management
Professional Nurse
AngloGold Health Services
Gauteng
09.2000 - 08.2002
- General nursing care of medical, surgical patients
- Deputy unit manager
- Administration work
- Wound care
- Administration of Medication
- Managing Scheduled drugs
- Preparation of patients going to theatre
- Managing patients from theatre
- Reason for leaving: Got married and relocated to my husband
Professional Nurse
Potchefstroom Hospital
North West
01.2000 - 08.2000
- General nursing care of medical, surgical patients
- Deputy unit manager
- Administration work
- Wound care
- Administration of Medication
- Managing Scheduled drugs
- Preparation of patients going to theatre
- Managing patients from theatre
- Reports writing
- Reason for leaving: Seeking Experience
Education
Certificate -Mental Health And Wellness in The Workplace - Mental Health
FPD-Foundation For Professional Development
Pretoria08-2022
Certificate Substance Abuse And Adolescents - Substance Abuse
FPD-Foundation For Professional Development
Pretoria08-2022
Certificate-Women And Mental Health - Mental Health
FPD Foundation For Professional Development
PRETORIA08-2022
Certificate -Pain Academy - Pain Management
PAIN-SA
Durban07-2022
Certificate-COVID-19 Vaccination Training For Health Workers - Vaccination
National Dept of Health
ONLINE05-2021
RE5-Regulatory Examination-REP – Moon Stone. - RE5-Regulatory Examination
Moon Stone
Pretoria08.2016
HIV/Aids Care And Counseling - HIV/AIDS Care And Counseling
UNISA
PRETORIA06-2007
Certificate in Oncology Nursing Science - Oncology Nursing
UNISA
PRETORIA12.2006
Performance Management - Performance Management
Health Advance Institute
PRETORIA04.2005
Bachelor of Science - Degree in B Cur Nursing Mangt And Admin And Educat
University Of North West(Potchefstroom University)
Potchefstroom12.2004
Diploma in Comprehensive Nursing Science - Nursing Science
Excelsius Nursing College
Klerksdorp Hospital Campus12.1999
Diploma in Computer Package - Computer Science
SE Business College
Johannesburg12-1995
Skills
- Advanced Communication Skills
- Management Skills
- Performance Management Skills
- Conflict Management Skills
- Negotiation skills
- Report Writing and Verbal Presentation Skills
- Financial Skills
- Monitoring and Evaluation Skills
Languages
English
First Language
Timeline
Clinical Consultant
PPS HealthCare Administrators
05.2017 - Current
Clinical Claims Adjudicator
Rand Mutual Assurance
03.2015 - 04.2017
Oncology Unit Manager
Netcare Pretoria East Hospital
11.2014 - 02.2015
Clinical Consultant-Managed Health Care-Case Manager
Keyhealth Medical Aid
06.2011 - 10.2014
Oncology Case Manager
Metropolitan Health Group
09.2008 - 04.2011
Case Manager
Muelmed Mediclinic Hospital
05.2007 - 08.2008
Unit Manager
Muelmed Mediclinic Hospital
01.2005 - 04.2007
Professional Nurse
Muelmed Mediclinic Hospital
09.2004 - 12.2004
Professional Nurse
AngloGold Health Services
09.2000 - 08.2002
Professional Nurse
Potchefstroom Hospital
01.2000 - 08.2000
Certificate -Mental Health And Wellness in The Workplace - Mental Health
FPD-Foundation For Professional Development
Certificate Substance Abuse And Adolescents - Substance Abuse
FPD-Foundation For Professional Development
Certificate-Women And Mental Health - Mental Health
FPD Foundation For Professional Development
Certificate -Pain Academy - Pain Management
PAIN-SA
Certificate-COVID-19 Vaccination Training For Health Workers - Vaccination
National Dept of Health
RE5-Regulatory Examination-REP – Moon Stone. - RE5-Regulatory Examination
Moon Stone
HIV/Aids Care And Counseling - HIV/AIDS Care And Counseling
UNISA
Certificate in Oncology Nursing Science - Oncology Nursing
UNISA
Performance Management - Performance Management
Health Advance Institute
Bachelor of Science - Degree in B Cur Nursing Mangt And Admin And Educat
University Of North West(Potchefstroom University)
Diploma in Comprehensive Nursing Science - Nursing Science
Excelsius Nursing College
Diploma in Computer Package - Computer Science
SE Business College
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