Medical Case Manager

4 weeks ago


Pretoria, Gauteng, South Africa Qetello Holdings Full time
Job Title: Medical Case Manager

Our client, a leading medical scheme, is seeking a dedicated and experienced Medical Case Manager to join their team. The successful candidate will be responsible for planning and optimizing daily tasks to ensure timely updates of cases on the hospital list.

Key Responsibilities:

  • Follow up on long-term and high-cost cases of hospitalised and home care patients.
  • Identify the need for patient and hospital visits and provide documented feedback.
  • Adhere to the escalation process for cases requiring input from management or the medical advisor.
  • Manage telephonic calls and enquiries from clients and service providers efficiently.
  • Coordinate services and care to prevent re-admissions and complications.
  • Negotiate tariffs and discounts within scheme rules.
  • Identify members for transfer to rehabilitation, sub-acute, and private nursing facilities for quality and cost-effective services.
  • Initiate discharge planning early in hospital admission.
  • Educate families about short-term medical benefits and general care exclusions.
  • Communicate discharge plans and benefits to relevant parties.
  • Document all communication and complete relevant information accurately.
  • Communicate clinical funding recommendations to doctors, members, suppliers, and service providers.
  • Identify and manage complicated and high-cost cases impacting the scheme financially.

Requirements:

  • B Cur Degree / Diploma in Nursing.
  • Minimum 5 years of experience as a nursing practitioner.
  • At least 1 year of experience in the medical funding industry.
  • Knowledge of ICD-10 & CPT coding, medical scheme rules, ERP, Workflow, and CAM.

What We Offer:

  • Competitive salary commensurate with experience.
  • Exceptional benefits program including 23 days of annual leave, 8-hour workday with a 30min break, life cover, disability benefits, funeral cover, pension fund, medical aid, and more.
  • Office perks: free parking, Wi-Fi, landline phone allowance, on-site gym, subsidised meals, free refreshments, Athletics Club, Pilates, and wellness programs.
  • Dynamic team interactions, recognition programs, and incentives.

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