Case Manager

7 months ago

Cape Town, South Africa Palesa Mbali Group Full time

**Position Purpose**:
To facilitate the setting of quality standards, policies, and procedures (clinical and non-clinical) for area. Ensure adherence to audit requirements, reporting and planning through evaluation, and coaching internal resources.

**Experience**:
5 years’ experience in the Managed Care environment in pre-authorisation call centre/ hospital case management or hospital claims. Working experience with a team of medical advisors will be an added advantage.

***

**Qualifications**

Enrolled or Registered Nurse

**Generic Output Details**

**Accountabilities**

**Continuous improvement**:

- Review and write clinical rules and processes
- Develop clinical policies, procedures and and maintain other business rules related to business unit, to ensure optimal automation
- Systematically monitor and review all policy changes
- Demonstrate independent decision making in the evaluation and feasibility of requests for system improvements and policies / processes
- Interact with team members at all levels of the business in decision making
- Liaise with all other Service Network Providers and Medscheme Operational areas to successfully develop Standard Operating Procedures
- Deliver approved, signed off and published Standard Operating Procedures
- Create and maintain clinical and non-clinical policies and procedures
- Implement practical solutions that use the specialist and departmental systems and processes
- Provide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisation
- Identify problems and develop and propose solutions to present to appropriate leader or stakeholders
- Ensure day to day operational support required from area of specialisation is provided to enhance performance

**Cost containment**:

- Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisation
- Continuously review cost / benefit and Return on Investment within area of specialisation Drive customer-centricity:

- Maintain a high level of impact on other departments to support improved delivery
- Continually increase understanding of client and stakeholder needs, satisfaction and service delivery

**Knowledge management**:

- Set up and maintain document library
- Coach internal resources on new Standard Operating Procedures
- Ensure that adequate knowledge regarding specialisation is shared as required and maintained within the research library
- Provide advice and / or training as required
- Maintain, develop and implement specialist knowledge within the day to day operations of the organisation

**Maintain expertise level**:

- Be a member of related professional bodies
- Ensure CPD (continual professional development) or similar accreditation requirements

are met annually to ensure maintained specialist accreditation

**Network key relationships**:

- Engage with and provide support to the established network of internal and external expert resources and partners

**Specialist support to projects**:

- Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when required
- Conform to project management disciplines when participating in projects
- Represent department or project on appropriate committees related to area of specialisation

**Position Specific Outputs**
- Communication with third parties
- Approval of all GEMS radiology cases, radiology experience would be advantageous
- Compile and maintain weekly statistics.
- Daily communication to Business unit Managers, Team leaders - MA availability / Late cover / TAT.
- Arrange and/or coordinate second opinions
- Obtain discounted quotes
- Obtain clinical information by contacting Member/Providers.
- Review and refer escalations to Medical advisors
- Refer to Medical advisors if MA clinical input is required.
- Review cases referred to Medical advisors within our scope of practice according to policies and Scheme rules. Support the Medical advisors and team with any administrative functions where required.

**Competency Requirements**

**Attribute**:

- Influence
- Entrepreneurship
- Credibility
- Ownership
- Collaboration

**Knowledge**:

- Knowledge and understanding of scheme rules

and products
- Knowledge of Quality Assurance methodologies
- Knowledge of policies and procedures

**Skill**:

- Numerical Ability
- Data modelling and evaluation
- Attention to Accuracy and Detail
- Problem solving and decision making skills
- Computer Technology Skills
- Task Management
- Executive Business Writing Skills
- Adobe Creative Suite
- Customer Focus
- Communication Skills

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