Clinical Case Manager for Spinal Management Program

1 day ago

Pretoria, Gauteng, South Africa H2R Full time
Job Title: Clinical Case Manager for Spinal Management Program

H2R is seeking a highly skilled Clinical Case Manager to join our team in the Spinal Management Program. As a key member of our team, you will be responsible for managing the access, clinical appropriateness, and risk of all requests for services related to back and neck pain management, spinal surgery, scans, and associated healthcare services.

Key Responsibilities:
  • Support the Medical Advisor and action all requests made by him/her.
  • Take guidance and instruction from the Medical Advisor.
  • Integrate skills and knowledge of pathophysiology, epidemiology, clinical management, and patient self-management to holistically review healthcare service and/or authorisation requests received within the Spinal Management Programme.
  • Critically review procedural clinical coding and prosthesis quotations received with requests for spinal surgery.
  • Actively engage both beneficiaries and healthcare service providers.
  • Case management of hospitalised patients.
  • Discharge planning.
  • Follow up on active cases with service providers relating to funding levels and updates (daily).
  • Interpretation of medical reports.
  • Clinical decision making.
  • Perform comprehensive assessments for each patient and facilitate/perform follow-up in accordance with the schedule determined/agreed.
  • Document all individual contacts and outcomes data in accordance with the guidelines in a timely manner.
  • Call and written contact with members and Providers.
  • Prepare reports/case studies as required.
  • Performs other duties as assigned within the Managed Healthcare environment.
Requirements:
  • Matric/Grade 12
  • Registered Nurse with valid registration with SANC OR Clinical Associate (Bachelor of Clinical Medical Practice (BCMP)) with valid registration with HPCSA
  • Thorough, well-grounded clinical knowledge of hospital admissions, LOS and LOC.
  • Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10's, CPT4, NRPL, PMB conditions and clinical protocols.
  • Extensive clinical knowledge related to all aspects of holistic patient management.
  • Work experience within Orthopaedic and/or Surgical theatre and wards will be advantageous.
  • Solid understanding of value-based care.
  • Demonstrated ability to manage a portfolio of active patient cases and to accurately update and maintain patient case information.
  • Outcome focused with the ability to manage competing demands.
  • Establishing and maintaining effective relationships with key stakeholders.
  • Excellent telephonic and written communication skills.
  • Computer literate - MS Office Suite (intermediate) required. MIP Application System experience will be advantageous.
  • Reporting – MS Excel (intermediate) required.
  • Proficiency in English – verbal and written.
  • Verbal proficiency in at least two others of the national languages will be advantageous.
  • Demonstrated ability to effectively deal with emotionally charged and stressful situations.
  • Compassionate and attentive listener – you will need to interact with the family members.
  • Self-motivator and the ability to work effectively in an independent environment.
  • Strong organisational and task prioritisation skills.
  • Outstanding multitasking skills.
  • Ability to research and analyse information.
  • High degree of accuracy and attention to detail.
  • Maintaining confidentiality of information.
  • Knowledge of Medical Aid policies and procedures.
  • Interest in and/or knowledge of Neuro-, Orthopaedic- and Spinal surgery.
  • Decision making skills.
  • Following through on commitments.

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