Clinical Case Manager

1 day ago


Johannesburg, Gauteng, South Africa Edge Executives Full time
Job Summary

We are seeking a highly skilled Clinical Case Manager to join our team at Edge Executives. As a key member of our healthcare operations team, you will be responsible for managing hospital admissions, conducting clinical assessments, and coordinating with healthcare providers to ensure the most efficient and cost-effective care is delivered to patients.

Key Responsibilities
  1. Clinical Case Management
  • Review hospital admissions to ensure clinical appropriateness and adherence to scheme rules and clinical guidelines.
  • Conduct pre-admission, admission, and discharge planning to optimize patient outcomes and reduce length of stay.
  • Coordinate with healthcare providers to ensure seamless care transitions and minimize unnecessary hospital stays.
Clinical Assessments and Authorisations
  • Perform comprehensive clinical assessments to inform treatment decisions and ensure alignment with clinical guidelines.
  • Approve or recommend alternative care options based on medical necessity and scheme rules.
  • Authorise hospital admissions, procedures, and specialist treatments in accordance with policy and clinical protocols.
Collaboration with Providers
  • Communicate regularly with healthcare providers to review patient progress and treatment plans.
  • Facilitate case conferences to improve patient outcomes and ensure integrated care.
  • Liaise with multi-disciplinary teams to ensure coordinated patient care and support appropriate care pathways.
Cost and Resource Management
  • Monitor and manage hospitalisation costs to align with scheme financial goals.
  • Identify cost-saving measures while ensuring high-quality patient care.
  • Monitor adherence to length of stay targets, care levels, and hospital resource usage to avoid unnecessary hospital stays and over-treatment.
Risk and Compliance Management
  • Ensure compliance with clinical and regulatory guidelines, scheme rules, and hospital policies.
  • Identify and manage clinical risks to implement interventions that align with scheme objectives.
  • Maintain accurate and timely documentation of case management activities and comprehensive records for auditing and reporting purposes.
Reporting and Documentation
  • Prepare and maintain detailed case reports for each patient, documenting clinical interventions, hospital admissions, and discharge planning.
  • Provide regular updates to management on key case management metrics, including costs, compliance, and patient outcomes.
Requirements
  • Education: Registered Nurse or Healthcare Professional with relevant clinical qualifications.
  • Professional Membership: Registered with the South African Nursing Council (SANC) or relevant professional body.
  • Experience: Minimum of 3-5 years of clinical experience in a hospital environment, with at least 2 years of experience in case management or managed care.
  • Skills: Proficiency in clinical assessments, hospital billing, and discharge planning. Understanding of healthcare systems and regulations.


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