Case Manager X3

3Sixty Health has a great opportunity for a suitably qualified individual to fulfil the advertised position and join their team.

3Sixty Health is a black owned and managed, reputable and a major player in driving

**3SIXTY HEALTH **South African economy by investing in ‘’black excellence’’3Sixty Health is 100% black

**BACKGROUND **owned and black managed administrator. It is accredited by the council for medical schemes to offer both administration and managed care services, allowing for a fully integrated, beneficiary-centric approach. Our core competencies in administration include membership management, billing, claim adjudication and customer services.

It is a medical aid administrator of Sizwe Hosmed Medical Scheme.

Case Manager

**POSITION**

Operations Admin

**DIVISION**

Managed Health Care

**DEPARTMENT**

Head Office, Houghton, Gauteng

**LOCATION**

Promote optimal, quality, cost-effective health care services to members admitted in high-cost wards, throughout the continuum of care whilst in a healthcare facility without compromising quality of care. Ensure proper risk management and integration of

**JOB PURPOSE**
preventative healthcare services with the objective of promoting self-management and better control of chronic conditions.

**KEY RESPONSIBILITIES**
- Using clinical expertise to review, monitor, and coordinate specialty services admissions, proposed surgical procedures, utilizing approved clinical guidelines,
- Reviewing clinical reports and records to determine medical necessity of proposed procedures and coordinating services at the appropriate level of care,
- Identifying and managing members in need of intensive case management and targeted disease
- management initiatives,
- Discussing cases with Medical Advisor regarding appropriateness of care and alternatives, and other services to meet the
- Reviewing covered benefits and alternative community and government-based programs that may be available to member,
- Monitoring patient outcomes: analysing existing policy and providing feedback as indicated.
- Contributes to the team effort, maintains customer confidence, and identifies potential quality issues by attending department meetings, giving and receiving feedback,
- Performing other duties and assignments as requested; accomplishing related results as needed; keeping information confidential; communicating quality of care issues.
- Fostering relationships with staff at assigned hospitals to improve coordination of care at appropriate levels.
- Handling of queries effectively and efficiently
- Analysing and review of High-cost cases for presentation to clinical operations team
- Handling of ex-gratia and CMS cases

**REQUIRED QUALIFICATIONS & EXPERIENCE**
- Registered Nurse (with SANC) with at least 3 years Private Hospital experience
- A sound knowledge of hospital claims and charges (NHRPL)
- Sound knowledge of the Medical Schemes Act
- Sound knowledge of Prescribed Minimum Benefits.
- Good planning and prioritising abilities
- Good analytical and problem-solving capabilities
- Good computer skills (MS Word, MS excel, PowerPoint)
- Excellent communication skills, both verbal and written
- Hi Care / ICU / theatre experience advantageous.
- Case management experience at least 2 yrs.
- Code 8 driver’s license an advantage.
- **COMPETENCIES**:

- Ability to work under pressure and as part of a team.
- Willingness to work overtime when necessary.
- Enthusiasm to accept and develop in a changing environment.
- Attention to detail and accuracy.
- Able to take responsibility and use own initiative

**Job Type**: Permanent

Ability to commute/relocate:

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

Application Question(s):

- Do you have sound knowledge of hospital claims and charges (NHRPL)?

**Education**:

- High School (matric) (required)

**Experience**:

- Registered Nurse (with SANC) with at least Private Hospital: 3 years (required)
- Case management: 2 years (required)

Application Deadline: 2023/09/10