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Case Manager

3 months ago

Pretoria, Gauteng, South Africa iMedrecruit Full time
About the job Case Manager (Member Management) 12 Month FTC - Pretoria

Case Manager (Member Management) 12 Month FTC - Pretoria
Our client, focusing on a risk and clinical assessment offering, is requiring a Case Manager (Member Management).

Requirements (but not limited to)

  • Perform Clinical coding in accordance with CPT and ICD requirements and as per client standards.
  • Maintaining patients clinical status in accordance with funder approval requirements for the duration of hospitalisation; keeping patients informed and managing the entire hospital stays 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
  • Discharge planning
  • Communication with and support to Medical Advisors
  • Call and written contact with Members and Providers
  • Contact SMS with members
  • Follow up on active cases with service providers relating to funding levels and updates (daily)
  • Interpretation of medical reports
  • Clinical decision making

Qualification:

  • 3 to 5 years experience within a managed healthcare or medical scheme environment
  • Enrolled/ Registered Nurse
  • Valid registration with SANC

Skills and attributes:

  • 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. ICD10s, 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
  • Outcome focused with the ability to manage competing demands
  • 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
  • Demonstrated ability to effectively deal with emotionally charged and stressful situations
  • Selfmotivator and the ability to work effectively in an independent environment
  • Strong organisational and task prioritisation skills
  • Outstanding multitasking skills
  • Ability to research and analyse information
  • High degree of accuracy and attention to detail
  • Maintaining confidentiality of information
  • Knowledge of medical aid policies and procedures.
  • Decision making skills
  • Following through on commitments
  • Flexibility to travel and a valid drivers license
  • Hospital case management experience will be advantageous
  • Nursing experience in an ICU setting will be a big advantage

Working hours:

  • Shift work between 7h00 and 19h00 (Monday to Sunday).
  • 12 Month FTC

Start Date:
ASAP
**ASAP