Case Manager - Pretoria, South Africa - Careforce Recruitment

Careforce Recruitment

Verified Company

Pretoria, South Africa

1 week ago

Posted by:

Thabo Mthembu

beBee Recruiter

Description

Position:
Case Manager (Member Management)

Reporting to:
Senior Specialist Clinical Management

Location:
On-site at the Head Office, Pretoria

Qualifications:

Enrolled/ Registered Nurse
Valid registration with SANC

Skills and Competencies Required:

3 to 5 years' experience within a managed healthcare or medical scheme environment
Thorough, wellgrounded clinical knowledge of hospital admissions, LOS and LOC.
Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10's, CPT4, NRPL, PMB conditions and clinical protocols
Extensive clinical knowledge related to all aspects of patient management.
Solid understanding of valuebased care
Demonstrated ability to manage a portfolio of hospital cases
Establishing and maintaining effective relationships with key stakeholders.
Ability to accurately update and maintain cases information.
Excellent telephonic and written communication skills (will be tested)

Computer literate

MIP Application System and MS Office

Reporting

MS Excel basic knowledge required (will be tested)
Proficiency in English verbal and written
Verbal proficiency in additional languages will be advantageous
Compassionate and attentive listener you will need to interact with the family/ loved ones of members with longstay hospital events
Selfmotivator and the ability to work effectively in an independent environment
Outstanding multitasking skills, strong organisational and task prioritisation skills
Ability to research and analyse information
Decision making skills, high degree of accuracy and attention to detail
Knowledge of medical aid policies and procedures and maintaining confidentiality of information
Flexibility to travel and a valid driver's license
Hospital case management experience will be advantageous
Nursing experience in an ICU setting will be a big advantage

Internal Application Requirements:

Will be required to work in accordance with a shift roster

Summary of Responsibilities:

Perform Clinical coding in accordance with CPT and ICD requirements and as per client standards
Maintaining patient's clinical status in accordance with funder approval requirements for the duration of hospitalisation; keeping patients informed and managing the entire hospital stay's financial risk
Provide complete and accurate updates and discharge information
Receive hospital updates and assess each case based on clinical info allocation of appropriate length of stay if clinically necessary
Update Level of Care based on clinical information
Review the costs to ensure cost effective and necessary care; balance cost and effectiveness of treatment to reduce readmission
Investigate and prepare cases for communication to the medical advisors, scheme, providers, and members
Member management of hospitalised patients with Chronic conditions who are registered on the active disease management programmes
Facilitation of the chronic and active disease registration of hospitalised beneficiaries who are diagnosed with one or more CDL conditions
Escalation and resolution of unresolved highcost cases
Identification and preparation of high cost / high risk incidents and reported weekly to Clinical Specialist
Communication with and support to Medical Advisors
Call and written contact with Members and Providers
Follow up on active cases with service providers relating to funding levels and updates (daily)
Interpretation of medical reports and Clinical decision making