Case Manager

4 days ago


Johannesburg, South Africa Medical Placements Full time

Case Manager is responsible for developing and implementing intensive multifaceted risk management interventions on a patient-specific basis with the purpose of preventing or reducing the medical schemes’ exposure to potentially high-cost members (in/out of hospital) who have been identified and risk stratified through claims analyses and clinical criteria.

**Duties**
- Use prepared lists of potentially high-risk patients, identified and stratified according to the level of risk, to prioritize and schedule risk management interventions.
- Further provides hospital utilisation management, education/training, and other clinically based activities as assigned, to coordinate care between the medical scheme/managed care organisation, members, providers and the community
- Ensure that all risk management interventions are patient-specific.
- Perform desk research to analyses the patient’s medical profile and claiming behaviour to develop possible action plans to ensure that the patient is receiving the level and extent of care necessary for optimal management of his/her condition(s), possible action plans for improving patient adherence to treatment and possible action plans regarding lifestyle measures required to assist in mitigating the clinical risk.
- Engagement telephonically with patients to agree on strategies and specific, detailed action plans to improve the patient’s medical prognosis and optimal disease control.
- Identify areas where the member requires education and support and provide such.
- Engage with the third-party Managed Care Partners and Medical Providers to request specific health information to provide an update of a member's healthcare status and facilitate registration on the appropriate programs and authorization of care baskets.
- Set achievable goals and targets for the member to achieve i.e., visit their doctor every 6 months, have specific investigations performed at scheduled dates, lose a specified number of kilograms in a defined time period, reduce their blood pressure to 120/80, reduce their HbA1c to a specific level by a certain date, etc.
- Ensure that the member understands how to take their medicines and the need to remain adherent to their treatment.
- Help the patient make any arrangements necessary to receive optimal care and to adhere to their treatment plan and schedule.
- Communicate with the patient’s provider when necessary to coordinate care.
- Identify if the patient needs to be referred to specialist care, or have a second opinion, and assist in facilitating or arranging this.
- Arrange for patients to join support groups, enrol on the Scheme’s exercise program, dietitian program, etc., as the case may be.
- Monitor and track adherence to the agreed action plan, per patient, through claims analyses and ongoing patient engagement.
- Engage telephonically with every identified patient at least once a month to ensure adherence to action plans.
- Engage and collaborate with the clinical team for support and advice where required
- Perform site visits, where required, for high-cost patients in hospital to contain costs and coordinate and arranging cost-effective care in collaboration with the treating Doctor and facilitate discharge planning.
- Arranges for the member to be transferred to an alternative facility when on-going care is required. - Refers patients to Disease Management, where appropriate, during a hospital admission
- Monitor and record all patient interactions and action plan goals to measure the success of the interventions.
- Produce reports (statistics) to demonstrate patient progress, patient outcomes, and pre-and post-intervention outcomes.
- This person will be responsible to effectively communicate and deliver an uncompromising quality of service to all internal and external customers by ensuring that all clinical updates and coding are of the highest standard.
- Ensure adherence to Scheme Rules on all authorisations and clinical updates where applicable.
- Assist with Health Risk Management Monitoring & Management of hospital re-admissions
- Compile & submit detailed reports to the Scheme on costs and patient’s progress
- Support the Clinical Manager and HOD on any projects related to risk management.
- Meet the required daily targets and daily operational delivery within the Clinical Risk Division according to set Service Level Agreements (SLA’s) and the Performance Contract.
- Develop and maintain a general clinical understanding of Tariff coding, ICD, CPT, SAMA, RPL and National Pharmaceutical Product Interface (NAPPI) codes, and how these affect clinical billing rules.
- Assist with the review of policies, protocols, tariffs, NAPPI codes from a clinical and financial position.
- Provide the Medical Advisor with supporting documents for motivation for additional services payments on special cases.
- Attend to complaints, queries, and escalations.
- Monitor outputs and results to inform process efficiencies to achieve targets.


  • Case Manager

    1 week ago


    Johannesburg, South Africa Clinix Health Group (Pty) Ltd Full time

    **Job Summary**: To deliver an effective case management process and facilitate the communication process between all role-players by providing accurate and timeous clinical information in order to minimize the financial risk for the company. **Minimum Qualifications and Experience**: - Grade 12. - Registered Nurse, currently registered with SANC. -...

  • Case Manager

    7 days ago


    Johannesburg, South Africa Clinix Health Group (Pty) Ltd Full time

    To deliver an effective case management process and facilitate the communication process between all role-players by providing accurate and timeous clinical information in order to minimize the financial risk for the company. **Minimum Qualifications and Experience**: - Grade 12. - Registered Nurse, currently registered with SANC. - Alternatively, an...

  • Case Manager

    7 months ago


    Johannesburg, South Africa Mass Staffing Projects Full time

    **Job Information** - Location- Johannesburg- Salary- R400k-R300k- Job Type- Permanent- Education- Degree/Diploma in Nursing- Experience- +2 years’ experience in case management- - pharmacy.jobs(at)staffingprojects.co.za- Fax- 0866023398This just in! A vacancy for a case manager at a private hospital in Johannesburg is currently...

  • Case Manager

    7 months ago


    Johannesburg, South Africa Medical Placements Full time

    Case Manager is responsible for developing and implementing intensive multifaceted risk management interventions on a patient-specific basis with the purpose of preventing or reducing the medical schemes’ exposure to potentially high cost members(in/out of hospital) who have been identified and risk stratified through claims analyses and clinical criteria....

  • Case Manager

    7 months ago


    Johannesburg, South Africa Palesa Mbali Group Full time

    **Case Manager** **Position**: Case Manager **Department**: General and Specialized Case Management **Grade**: B4M1 **Position Purpose**: **Experience**: 5 years ward experience, 2 years’ experience hospital scheme case management advantageous **Qualifications**: Degree / Diploma in nursing, midwifery, and psychiatry. Current SANC professional nursing...

  • Case Manager

    7 months ago


    Johannesburg, South Africa LetsLink Pty Ltd Full time

    Role Title: Case Manager Role Summary: Are you a healthcare professional looking to make a significant impact in patient care and financial risk management? If so, we have an exciting opportunity for you to join the team of a private hospital based in Gauteng as a Case Manager. In this role, you will leverage your clinical knowledge and expertise to ensure...

  • Case Manager

    7 months ago


    Johannesburg, South Africa Clinix Health Group (Pty) Ltd Full time

    To plan, coordinate and execute case management work at hospital level. The incumbent utilities clinical knowledge to minimise financial risk and ensure accurate billing through comprehensive accurate coding of patient care. **Minimum Requirements**: - Relevant Nursing qualification. - CM or Billings Clerk with ICD training and anatomy and physiology...

  • Case Manager

    4 months ago


    Johannesburg, South Africa Clinix Health Group (Pty) Ltd Full time

    **Job Summary**: To plan, coordinate and execute case management work at hospital level. The incumbent utilities clinical knowledge to minimise financial risk and ensure accurate billing through comprehensive accurate coding of patient care. **Minimum Qualifications and Experience*** - Nursing degree / diploma. - Current registration with South African...

  • Case Manager

    7 days ago


    Johannesburg, South Africa Mass Staffing Projects Full time

    **Requirements**: - Registered with the SANC - Degree/Diploma in Nursing - +3 years’ experience case management - Experience with CPT4 coding and ICD10 coding

  • Case Manager

    2 weeks ago


    Johannesburg, South Africa Mass Staffing Projects Full time

    Open vacancy in Gauteng! Looking for a someone that will be responsible for the liaison between the patients and managed healthcare. **Requirements**: - B Degree Nursing Qualification or equivalent NQF level 6 - Hospital case manager experience advantageous - 3 years’ experience in patient care - SAP experience preferrable

  • Case Manager

    5 days ago


    Johannesburg, South Africa Mass Staffing Projects Full time

    Exciting opportunity in Gauteng! Looking for a someone that will be responsible for the liaison between the patients and managed healthcare. **Requirements**: - B Degree Nursing Qualification or equivalent NQF level 6 - Hospital case manager experience advantageous - 3 years’ experience in patient care - SAP experience preferrable

  • Case Management Lead

    11 hours ago


    Johannesburg, South Africa Complement Recruitment Full time

    Complement Recruitment are recruiting for a Case Management Lead for a permanent position based in Sandton, Johannesburg, Gauteng. Our client is looking for an experienced, commercially minded and operationally strong case management lead with a proven track record of implementing and streamlining projects and making sure they have high impact for the...


  • Johannesburg, South Africa Motor Industry Bargaining Council Full time

    **Duties & Responsibilities** - Monitor and account for stationery, consumable levels - Attend to professional drafted correspondence, serving and courier documents - Generate case management Reports when requested - Assist at reception(front office) or other Case Manager’ when required, - Book venues, Interpreters and Panelist for cases with proper notice...

  • Case Manager

    5 days ago


    Johannesburg, South Africa Mass Staffing Projects Full time

    **Requirements**: - Registered with the South African Nursing Council (SANC) as a Registered Nurse Degree or Diploma essential. - Minimum of 3 years in a multidisciplinary hospital environment. - Previous/current experience as a Case Manager is advantageous. - ICD-10 and CPT coding experience is essential. - A minimum of 1-2 years in computer literacy is...


  • Johannesburg, South Africa Rand Mutual Assurance Full time

    **THE JOB AT A GLANCE** To deliver coordinate case management: through the three pillars clinical rehabilitation, vocational rehabilitation, and social reintegration. Track progress of injured COID employees referred to RMA Rehab Team, liaise with therapy team, with the purpose of prevention of complications, and guide the process of restoration to...

  • Case Manager

    6 days ago


    Johannesburg, South Africa Premier Appointments Full time

    **Case Manager** 1. **Qualifications**: - Matric - Registered Nursing diploma - Valid membership of SANC - Claims and Forensic Risk management certification - Registration with the Association of Certified Fraud Examiners (ACFE SA) 2. **Skills and Experience**: - At least 2-3 years’ experience in a similar role. - MIP Application System experience...


  • Johannesburg, South Africa AristoSourcing Inc. Full time

    AristoSourcing LLC is an Outsourcing company highly focused on the Digital Marketing Industry. Our company has been in the industry for more than 7 years. We hired and referred skilled and experienced Virtual Assistants to work and collaborate directly with our respective clients from different parts of the globe that offer 100% remote work for talented and...


  • Johannesburg, South Africa Palesa Mbali Group Full time

    **Position**: Case Manager In Hospital **Position Purpose**: To coordinate care in allocated facilities, in order to improve health outcomes and manage the cost to the Scheme(/s). The case manager's responsibilities start from patient admission to discharge and they should have an understanding of hospital processes and the importance of making...

  • Clinical Case Manager

    3 months ago


    Johannesburg, South Africa MHR Full time

    **Job Advert Summary**: Our client, a leader in the private healthcare industry, is urgently looking for an experienced **Case Manager** for a** **permanent opportunity** **at a private** Emergency Services Contact Centre** in **Rivonia (Johannesburg)**. **BENEFITS** - Pension fund membership and subsidy from the company - Medical aid membership and subsidy...

  • Case Manager

    4 months ago


    Johannesburg, South Africa Medical Protection Society Full time

    Job Introduction The Member Cases and Claims Division is at the forefront of protecting the careers, reputation and financial risk of our members worldwide. The purpose of the role is to support the provision of excellent case handling services for members which is trusted and valued and provides fair treatment and outcomes. The role will do this by managing...