Registered Nurse at Discovery Limited

Job Description

Key Purpose of the role

• To address day-to-day as well as policy issues relating to clinical queries emanating from coverage decisions, clinical protocols, baskets of care and formularies ensuring good clinical practices are followed.
• Areas of responsibility may include but not limited to
• Clinical policy development and support for internal business stakeholders.
• Identification of new areas, clinical conditions, and interventions where clinical policy support is required based on clinical need, healthcare improvement initiatives, new technologies, financial risk and any other risk management initiative.
• Undertaking of the design, development, implementation, training and monitoring effectiveness of new coverage decisions, clinical policies, protocols, baskets of care and formularies.
• Review and updating of existing coverage decisions, clinical policies, protocols, baskets of care and formularies.
• Communication, negotiation and liaison internally within Discovery Health as well as externally with manufacturers, suppliers, healthcare providers, and other stakeholders including various industry forums as may be mandated.
• Provide guidance to the business in terms of new and relevant clinical developments [e.g. new medicines, tests or technologies, legislation].
• Undertaking the design, development and maintenance of clinical content on DNA (Discovery intranet).
• Preparation of responses related to media queries where clinical matters are concerned
• Attend and represent the business unit and Discovery at conferences and presentations (during weekends and after hours as the need arises).
• Undertaking of any other specific projects as delegated from time-to-time by management.
• Sound clinical and benefit knowledge to address day-to-day as well as policy issues relating to clinical queries emanating from coverage decisions, clinical protocols, baskets of care and formularies.
• Ability to engage with health professionals and providers involved in the clinical care of members, on an individual case by case basis or policy related matters.
• Competent understanding of healthcare risk management.
• Thorough understanding of the medical schemes act, its regulations and amendments,
• Ability to navigate the Discovery intranet, authorization systems, claims payment systems, reporting tools and other relevant data systems

Education and Experience

• Bachelor’s Degree in Nursing
• Must be registered with the SANC and practising
• 5 years or more working in a professional nursing setting
• Additional training in evidence-based medicine is required.
• At least 3-5 years’ experience in a medical scheme and/or managed care environment in the area of clinical policy, research, benefit design and operations.
• Desk research experience (advantageous)
• Advanced computer literacy, especially with Microsoft Office (Word, Excel, PowerPoint)
• Previous experience in developing protocols, researching clinical evidence, familiarity with clinical coding (e.g. NHRPL, ICD-10 and CPT) will be an advantage.
• Experience in liaising and negotiating with manufacturers, suppliers, and providers will be an advantage.

EMPLOYMENT EQUITY

The Company’s approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply