Renee Devine

To work and succeed in a stimulating and challenging environment, building the
success of the company while I experience advancement opportunities

Theatre/Recovery Sister 6 years
Case Management 3 years
Medical Advisor 2 years
Specialist : Clinical Processes 3 years
Specialist : Clinical Claims Consultant 4years

CASE MANAGER/PRE AUTHORISATION

*End to End Authorisation Process ( including
authorisation for hospital and alternative facilities)
*ICD10 and CCSA Coding Reviews
In relation to admissions, theatre related procedures
and stock used(ward stock, pharmacy stock and theatre
related stock)
(Medical and Surgical)
*PMB and LOS Reviews ( pmb in accordance to
orthopaedic cases and any other related surgeries)
*High Cost Case Cost Containment and Reviews
*Alternative to hospitalisations
Recommendations
*Case reviews on a case by case
Basis
*Discharge planning (holistically)
*Nappi Codes in accordance to
Equipment utilisation as per
Coding Standards related PMB
*Standard Operating Procedure
adherence
*Scheme Rules and Hospital
Contracting relating to
escalations
*System enhancement innovation

MEDICAL ADVISOR

Management of High Cost Case Managers
Clinical Reviews and Presentations
Council of Medical Scheme Reviews and Preparations
Prosthetic Negotiations (Cardiac
and Orthopeadic)
Presentation of Complicated Cases at Clinical Review
Meetings
PMB Research in relation with all 7 provinces on Case
Findings
Coding Reviews
Standard Operating Procedure updates and
amendments
Clinical Policies research on new findings

SPECIALIST: CLINICAL PR

Standard Operating Procedure Writer
Clinical Policy Writer
System Enhancement and Functionality Analyst
Implementation of New Scheme Rules
Chairing Workshops for enhancement training
Year End Projects really new devopments
Implement of new Hospital Contracts
Policy Reviews yearly
Coding Reviews All codes
PMB UPDATES
Business Risk Analysis Financially
Cost Containment development and Implementation
Project report all in one surgeries (ARM MODELS )
Negotiations with all Hospital Groups
 

SPECIALIST: CLINICAL CLAIMS CONSULTANT

Auditing of Hospital Claims
Payment Analysis as per Hospital Contracting and
related Scheme Rules
Clinical Reviews read Short payments on Hospital
Claims
Stale Claims analysis, reviews and Clinical
Recommendations for payments
CCSA AND ICD10 correctness analysis re payments and
Hospital Admissions according to Billing, before
Processing and Reprocess of Claims
Medikredit Updates and adherence really protocol
payments
Fraud, Waste and Abuse Reporting really Risk Analysis
and Hospital Risk Alerts
PMB Reviews in accordance to Council of Medical
Schemes Act, Hospital Contracting and Related Scheme
Rules
Resolutions for Route Cause Analysis
Feedback on Error Finding really Claims and related
Correctness
Fraud Reporting
 

R425 Nursing Diploma (General, Community, Midwifery
and Psychiatry)