Hospital Case Manager bloubergstrand - Bloubergstrand, South Africa - Spescare

Spescare
Spescare
Verified Company
Bloubergstrand, South Africa

1 week ago

Thabo Mthembu

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Thabo Mthembu

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Description
Spescare Bloubergstrand is currently looking for an Case Manager to join their team.

SUMMARY
Responsible for assisting in carrying out the hospital's case management plan. Educates staff regarding effective allocation of the hospital's resources while encouraging provision of high-quality patient care.

ESSENTIAL DUTIES AND RESPONSIBILITIES - BUT NOT LIMITED TO:

Admissions

  • Comply with company policies and procedures.
  • Patient Referral forms to be sent to Medical Aids.
  • Interacts with medical schemes to ensure that authorizations are provided timeously.
  • Conduct ward rounds and ensure the accurate complete collection of clinic data from patient files and liaisons with nursing staff and attending clinicians.
  • Verification of clinical coding as per policies and procedures.
  • Provides support for the management of alternative fee structures.
  • Interprets and implements scheme benefit rules.
  • Monthly reporting to be sent to Admin Manager (Monthly statistics referrals per doctor and Referrals vs patients admitted, may include other as determined by Admin Manager ).

Updates

  • Update accurate clinical information to justify, length of stay (LOS) and level of care (LOC) to medical funds the assigned managed care organization.
  • Update and provide the necessary information to funders regarding HV (high value) items, limited benefits and protocols as defined by managed care organizations.
  • Communicate medical aid's requirements / responses to attending clinicians and patients where necessary and ensure compliance with industry standards.
  • Ensure effective management of real time and manual messaging, including request, responses, rejections, and submissions.
  • Adherence to medical aid escalation processes.
  • Liaison with doctors on further requirements when necessary for motivating for LOS.
  • Communicate admissions, LOS, test results, requirements, and updates on electronic communication platform.
  • Understand and ensure adherence to patient's services policies and procedures.

Discharges

  • Ensure the accurate submission of accounts to funders.
  • Patient release, discharge update to be sent to medical aids.
  • Discharge update report to be sent to referring doctors and patient GP.

Claims and Billing

  • Ensure accurate and complete coding of patient accounts.
  • Auditing and final bill of all accounts.
  • Ensure events are updated and are accounts submitted to funder within 3 working days after discharge.
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Management Committee (MANCO)

  • Attend MANCO meetings.
  • Assist your team with task and responsibilities assigned to you as MANCO member.
  • Managing of hospital admin team and ensuring all tasks are completed in the allocated time frame, throughout the admin department.
  • Identifying a contingency plan for all functions in the hospital admin department, including induction training for back up support team members.
  • Ensuring all admin staff member receives the correct induction and training in the admin department.

Customer Service

  • Drive adherence to customer service standards.
  • Foster and maintain healthy relationships with stakeholders. E. g. nursing, pharmacy and business hubs.
  • Interacts with referring doctors and referring hospital staff to ensure that patients that need the service provided by the Company are referred.
  • Adherence to Complaint Management Policy, which indicates the complaint escalation process when patient complaints are lodged.
  • Continuous quality management.
  • Maintains client service principles to ensure client expectations are met.
  • Liaise with Manager regarding prioritization of work plan.

Education and/or Experience

  • Experience: Twoyear case management experience in a medium to large concern.
  • Knowledge and understanding of clinical coding (ICD10).
  • Education: Matric and Nursing background with relevant tertiary qualification.

Skills

  • Good English written and verbal communication.
  • Excellent telephone manner with an overall pleasant disposition.
  • Ability to be assertive when needed.
  • Flexible work style.
  • Collaborative able to work well with people within and outside the company.
  • Team player
  • Leadership skills
  • The Employer reserves the right to withdraw the advertisement at any time._
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