Case Manager

4 months ago

Pretoria, South Africa Oasis Healthservices Full time
The successful
candidate will be responsible for managing the financial and clinical risks of
the patient in a general ward by ensuring accurate coding, clinical updates
and accounts submissions of patient hospitalization to achieve strategic
objectives.
Critical Outputs
 Ensuring the maximisation of revenue by
 Ensuring accuracy of coding
 Ensuring the correct application and interpretation of RSRT’s
 Participating in meetings and reporting losses to RSRT team and
recommend corrective actions
 Monitoring insurance verification and workflow processes
 Ensuring effective management of quality outputs by
 Performing quality walkabouts and implement corrective measures
 Implementing and monitoring quality improvement programmes
 Adhering to patient services escalation processes in order to achieve
QMS targets
 Monitoring Q-evaluator scores and implementing corrective measures
 Investigating internal and external stakeholder complaints
 Ensuring the adherence to customer service standards
 Ensuring operational excellence by
 Monitoring submission of accurate accounts to funders
 Updating length of stay and level of care to medical aids
 Releasing care risk targets and submission within two days of discharge
 Ensuring the compliance to LHC policies and managing authorisations
and claim submissions, rejections and delays
 Ensuring governance and risk management by monitoring and adhering
to patient services policies and procedures
 Ensuring compliance to service level agreements with internal and
external stakeholders
 Ensuring all billing checks are closed by the relevant function areas
 Ensuring effective management of relationships with internal/external
stakeholders by
 Building and maintaining relationships with internal stakeholders
 Providing feedback and information on concerns or issues raised by
internal stakeholders
 Providing and facilitating training regarding RSRT contracts to the
relevant internal stakeholders
 Ensuring effective communication with external stakeholders
 Managing escalated concerns from Care Risk Managers with external
stakeholders
 Escalating doctor non-compliance in terms of RSRT framework to RSRT
meetings

Requirements
 Nursing Qualification, Professional Nurse with at least three to five
years’ experience
 Current SANC registration
 Knowledge of hospital patient services and case management
processes
 Knowledge and understanding of CPT & ICD coding
 Knowledge of Funder contracts, scheme rules, exclusions and benefits
 Understanding of private hospital industry and practices
 Computer proficiency

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