Medical / Managed Care Case Manager (EE)

Found in: Adzuna ZA B C2 - 1 week ago


Portelizabeth, South Africa Adzuna ZA B C2 Full time
Role Purpose
The purpose of this temporary role is to assist in the enhancement and management of cost-effective managed health care with the objective of promoting rational utilization of health care facilities and containing associated costs generated by these services for a period of 6 months only.

Requirements

  • A National Senior Certificate is essential.
  • It is essential to have a Nursing Diploma or Degree.
  • Minimum of 2 years clinical experience within a private hospital is essential.
  • The incumbent must be registered with SANC (South African Nursing Council) as a Registered Nurse.
  • A certificate in ICD-10 coding is highly advantageous.
  • Experience in a managed care / case management environment would be an advantage.
  • MS Office / Office 365 proficiency.
  • Be available to work at one of our offices based in Richmond Hill (Gqeberha), Cornubia (Durban), Bellville (Cape Town) or Centurion.
Duties
  • Review of in-hospital patients for appropriateness of care, length of stay and level of care.
  • Liaise with the service provider on clinical updates, as well as outstanding information.
  • Engage with the treating doctor(s) to ensure appropriate treatment, length of stay and level of care is rendered.
  • Discharge planning for in-hospital patients to ensure ongoing support and care post discharge.
  • Develop, implement and communicate the practice and/or clinical guidelines for cost effective care.
  • Authorize appropriate and cost-effective surgical care and treatment.
  • Ensure the consistent and correct application of exclusions.
  • Adhere to policies and procedures and take corrective action where necessary.
  • Adhere to organizational best practice and legislative requirements.
  • Take ownership of escalated and unresolved queries and ensure they are resolved timeously.
  • Manage queries until resolution and update the incident details.
  • Identify financial and business risks to the company and escalate accordingly.
  • Provide clinical support to non-clinical teams if/when required.
  • Drive and support effective teamwork within the department.
  • Strive to demonstrate the company's values daily.
  • Engage in hospital visits where needed to build stakeholder relationships, proactively resolve queries and increase visibility to members.
  • Ensure the effective, accurate and timeous completion of relevant documentation and recording of interventions.
  • Communicate with providers to improve the cost efficiencies of health care delivery.
  • Ensure Service Level Agreements are met and exceeded.
  • Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
Competencies
  • Effective communication skills verbal and written.
  • Accountability.
  • Planning and organizing.
  • Problem solving.
  • Time management.
  • Attention to detail.
  • Interpersonal skills.
  • Customer orientation.
  • Results driven.
  • Empathetic nature.
  • Business Administration skills.
Please consider your application unsuccessful if you are not contacted within two weeks of applying.
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