Case Manager

3 days ago

Johannesburg, South Africa MHR Full time

**Job Advert Summary**:
MHR is urgently looking for a **Registered Nurse Case Manager** with **Disease Management experience.** This is a **permanent opportunity** at a well-known medical aid** **in** Randburg** in** Johannesburg**.

**Minimum Requirements**:

- 5 years of case management and disease management experience
- Minimum of 3 years’ experience in high-risk patient case management or care coordination program within a medical scheme or managed care environment
- National Diploma in Nursing (General, Community Health, Midwifery, and Psychiatry)
- Diploma in Intensive care will serve as an added advantage
- Registered with SANC as a Registered Nurse

**Knowledge**
- Thorough medical knowledge
- Excellent Medical Aid Industry and claims assessing knowledge
- Good working knowledge of ICD10 coding and other clinical coding
- Clinical Risk Management, Risk Management practices and principles knowledge
- Sound knowledge of relevant legislation and regulatory frameworks

**Skills**
- Proven Business Acumen skills
- Excellent verbal and written communication skills
- Project Management skills
- Managed healthcare
- Problem Solving, Judgement and Decision-Making skills

**Attributes**
- Resilient
- Detail orientated
- Results and quality focused
- Compliance driven
- Innovative thinking
- Client-centric
- Analytical thinking

**Duties and Responsibilities**:
The 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.

**Key areas of responsibility**
- Use prepared lists of potentially high-risk patients, identified and stratified according to the level of risk, to prioritise and schedule risk management interventions.
- Further provide hospital utilisation management, education/training, and other clinically based activities to coordinate care between the medical scheme/managed care organisation, members, providers and the community.
- Perform desk research to analyse the patient’s medical profile and claiming behaviour to develop possible action plans, ensuring that the patient receives the level and extent of care required for the optimal management of his/her condition(s), possible action plans for improving patient adherence to treatment, as well as possible actions plans regarding lifestyle measures required to assist in mitigating the clinical risk.
- Engage telephonically with patients to agree on strategies, and specific and 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 authorisation 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 patient understands how to take their medicines and the need to adhere to their treatment.
- Help the patient make any arrangements necessary to receive optimal care and to adhere to their treatment plan and schedule.
- 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 and enroll 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.
- Perform site visits, where required, for high-cost patients in hospital to contain costs, coordinate and arrange cost-effective care in collaboration with the treating doctor, and facilitate discharge planning.
- Assist with Health Risk Management Monitoring and Management of hospital re-admissions.
- Support the Clinical Manager and HOD on any projects related to risk management.
- 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 in reviewing policies, protocols, tariffs, and NAPPI codes from a clinical and financial position.
- Provide the Medical Advisor with supporting documents for motivation for additional service payments on special cases.
- Research medical literature and use evidence-based principles to generate enhancements in funding

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