Case Manager

3 weeks ago


Gauteng, South Africa 3Sixty Health (Pty) Ltd Full time

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 South

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

**BACKGROUND ** 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:

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

Application Question(s):

- Do you have Hi Care /ICU experience?

Do you have sound knowledge of the medical scheme Act & hospital claims?

**Education**:

- High School (matric) (required)

**Experience**:

- Registered Nurse private hospital: 3 years (required)
- Case Management: 2 years (required)

Application Deadline: 2023/02/09


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