Case Manager

1 week ago

Pretoria, South Africa H2R Africa Full time

**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

Solid understanding of value-based 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 long-stay hospital
events
Demonstrated ability to effectively deal with emotionally charged and stressful situations
Self-motivator and the ability to work effectively in an in 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 procedure
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

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 re
- admission
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 high-cost 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

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