Case Manager

6 months ago

Pretoria, South Africa iMedrecruit Full time

About the job Case Manager (Member Management) 12 Month FTC - Pretoria

**Case Manager (Member Management) 12 Month FTC - Pretoria**

Our client, focusing on a risk and clinical assessment offering, is requiring a Case Manager (Member Management).

**Requirements (but not limited to)**
- 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

**Qualification**:

- 3 to 5 years experience within a managed healthcare or medical scheme environment
- Enrolled/ Registered Nurse
- Valid registration with SANC

**Skills and attributes**:

- 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. ICD10s, 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
- 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 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 procedures.
- 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

**Working hours**:

- Shift work between 7h00 and 19h00 (Monday to Sunday).
- 12 Month FTC

**Start Date: ASAP**

**ASAP

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