Case Manager

5 months ago

Pretoria, South Africa care force Full time

Our client, a managed care organisation based in Pretoria is looking for a Case Manager. This is an equal opportunity organisation with various businesses and/ or subsidiaries that service clients in the medical scheme and insurance industries.

Position: Case Manager (Member Management)

Reporting to: Senior Specialist Clinical Management

Location: On-site at the Head Office, Pretoria

Contract Type: Fixed Term Contract for period of **12 months** (with the possibility of becoming permanent thereafter)

**The purpose of the position**

To actively manage the clinical appropriateness and risk (both financial and clinical) of all hospital events and associated healthcare services in accordance with the relevant scheme rules, clinical protocols, and funding guidelines. To participate in the clinical review of exceptional cases and to engage with various stakeholders including treating providers, hospital case managers, medical advisors, and colleagues.

**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
- Thorough, well-grounded clinical knowledge of hospital admissions, LOS and LOC.
- Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols
- Extensive clinical knowledge related to all aspects of patient management.
- Solid understanding of value-based care
- Demonstrated ability to manage a portfolio of hospital cases
- 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
- Self-motivator and the ability to work effectively in an independent environment
- Outstanding multitasking skills, strong organisational and task prioritisation skills
- Ability to research and analyse information
- Decision making skills, high degree of accuracy and attention to detail
- Knowledge of medical aid policies and procedures and maintaining confidentiality of information
- Flexibility to travel and a valid driver’s license
- Hospital case management experience will be advantageous
- Nursing experience in an ICU setting will be a big advantage

**Summary of Responsibilities**:

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

**On Offer**:
**Job Type**: Temp to perm

Ability to commute/relocate:

- Pretoria, Gauteng: Reliably commute or planning to relocate before starting work (required)

License/Certification:

- SANC Registration (required)

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