Case Manager

2 weeks ago


Sandton, South Africa Watershed Consulting Full time

**Job Description**:
We are looking for a **Case Manager** who is a _Registered Nurse_ with a valid _SANC Membership_ and ideally has some experience in the healthcare insurance space. You will be handling incoming calls from Hospitals Case Managers relating to authorizations for procedures in hospitals, casualty, doctor, or dental provider rooms.

**Key Responsibility**:

- Hospital case management from issuing a guarantee of payment (GOP) to final discharge and any follow-up treatment where required.
- Manage clinical risk by promoting sound principles and strategies to decrease claims over utilization.
- Pre-authorisation of GP visits per benefit option rules.
- Classify and prioritize risks based on the frequency of member visits to a provider.
- Ensure efficient customer service and compliance with agreed SLAs.
- Follow up with healthcare practitioners and members who may be overutilizing visits and the “rooms” procedures.
- Manage and maintain data integrity and update accordingly where necessary.

**Qualifications**:

- Matric
- Registered Nursing Diploma
- Valid membership of SANC

**Skills and Experience**:

- At least 2-3 years experience in a similar role.
- MIP Application System experience an advantage.
- Sound understanding of the South African Health Industry, benefits, etc.
- ICD codes, modifiers, and RPL tariff knowledge and understanding.
- Ability to liaise with external parties - clinicians and members.
- Ability to work within an established team.
- Excellent oral and written communication skills.
- Customer-centric attitude.
- Excellent analytical skills and pays attention to detail.
- Computer literate - MS Office suite, i.e., Word, Excel.
- A good understanding of claims risk profiling.
- Experience in claims auditing.

**Skills**:
Registered Nurse



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