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Clinical Case Manager
2 months ago
Job Title: Clinical Case Manager
Job Summary: H2R Africa is seeking a highly skilled Clinical Case Manager to join our dynamic team. As a Clinical Case Manager, you will be responsible for managing the clinical appropriateness and risk of hospital events and associated healthcare services.
Key Responsibilities:
- Clinical Coding: Perform clinical coding in accordance with CPT and ICD requirements and as per client standards.
- Patient Management: Maintain patients' clinical status in accordance with funder approval requirements for the duration of hospitalisation; keep patients informed and manage the entire hospital stay's financial risk.
- Discharge Planning: Provide complete and accurate updates and discharge information.
- Clinical Review: Receive hospital updates and assess each case based on clinical information, allocating appropriate Length of Stay if clinically necessary.
- Level of Care: Update Level of Care based on clinical information.
- Cost Management: Review the costs to ensure cost-effective and necessary care; balance cost and effectiveness of treatment to reduce re-admission.
- Case Preparation: Investigate and prepare cases for communication to the medical advisors, scheme, providers, and members.
- Member Management: Manage hospitalised patients with Chronic conditions who are registered on the active disease management programmes.
- Chronic Disease Registration: Facilitate the chronic and active disease registration of hospitalised beneficiaries who are diagnosed with one or more CDL conditions.
- Incident Management: Escalation and resolution of unresolved high-cost cases.
- High-Risk Incident Identification: Identification and preparation of high-cost/high-risk incidents and reported weekly to Clinical Specialist.
- Communication: Communication with and support to Medical Advisors, call and written contact with Members and Providers, and contact SMS with members.
- Follow-up: Follow up on active cases with service providers relating to funding levels and updates (daily).
- Medical Report Interpretation: Interpretation of medical reports.
- Clinical Decision Making: Clinical decision making.
Requirements:
- Qualifications: Enrolled/Registered Nurse.
- Registration: Valid registration with SANC.
- Experience: 3 to 5 years of experience within a managed healthcare or medical scheme environment.
- Skills: 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 (ICD10s, CPT4, NRPL, PMB conditions, and clinical protocols); extensive clinical knowledge related to all aspects of patient management; solid understanding of value-based care; demonstrated ability to manage a portfolio of hospital cases; outcome-focused with the ability to manage competing demands; establishing and maintaining effective relationships with key stakeholders; ability to accurately update and maintain cases information; excellent telephonic and written communication skills; computer literate - MIP Application System and MS Office; reporting MS Excel basic knowledge required; proficiency in English verbal and written; verbal proficiency in additional languages will be advantageous; hospital case management experience will be advantageous; nursing experience in an ICU setting will be a big advantage.
