Risk Management Specialist

1 week ago


Pretoria, Gauteng, South Africa Oasis Healthservices Full time

Job Title: Case Manager

About the Role:

Oasis Health services is seeking an experienced Case Manager to join our team. As a Case Manager, you will be responsible for managing financial and clinical risks of patients in a general ward.

Key Responsibilities:

  • Ensure accurate coding, clinical updates, and accounts submissions to achieve strategic objectives.
  • Participate in meetings and report losses to the RSRT team and recommend corrective actions.
  • Monitor insurance verification and workflow processes.
  • Implement and monitor quality improvement programmes.
  • Adhere to patient services escalation processes to achieve QMS targets.
  • Monitor Q-evaluator scores and implement corrective measures.
  • Investigate internal and external stakeholder complaints.
  • Ensure compliance to LHC policies and manage authorisations and claim submissions.
  • Ensure governance and risk management by monitoring and adhering to patient services policies and procedures.

Requirements:

  • Nursing Qualification, Professional Nurse with at least three to five years' experience.
  • Current SANC registration.
  • Knowledge of hospital patient services and case management processes.
  • Knowledge and understanding of CPT & ICD coding.
  • Knowledge of Funder contracts, scheme rules, exclusions and benefits.
  • Understanding of private hospital industry and practices.


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