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Case Manager

3 weeks ago

Johannesburg, South Africa Premier Appointments Full time

**Case Manager**

1.

**Qualifications**:

- Matric
- Registered Nursing diploma
- Valid membership of SANC
- Claims and Forensic Risk management certification
- Registration with the Association of Certified Fraud Examiners (ACFE SA)

2.

**Skills and Experience**:

- At least 2-3 years’ experience in a similar role.
- MIP Application System experience and advantage.
- Sound understanding of the South African Health Industry, benefits, and options, etc.
- ICD codes, modifiers, and RPL tariff knowledge and understanding.
- Ability to liaise with external parties - clinicians and members.
- Ability to work within an established team.
- Excellent oral and written communication skills.
- Customer-centric attitude.
- Excellent analytical skills and pays attention to detail.
- Computer literate - MS Office suite, i.e. Word, Excel.
- A good understanding of claims risk profiling.
- Experience in claims auditing.

3.

**Reporting to**:
**Risk Manager**

4.

**Scope of Responsibility**:

- Overall responsibility for incoming calls from Hospitals Case Managers relating to authorisations for procedures in Hospitals, Casualty, Specialist, GP, or Dental provider's rooms.
- Hospital case management from issuing a guarantee of payment (GOP) to final discharge and any follow up treatment where required.
- All medicines related issues for special cases and off formulary items.
- Analyse clinical, utilisation, and other data of members and healthcare providers.
- Share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.
- Identify trends in utilisation, fraud, and other factors.
- Ensure that all calls and cases are fully and clearly recorded on the MIP system accordingly.
- Ensure efficient Customer Service and compliance to agreed SLA’s.
- Follow up with GP providers who may be over utilizing the “in rooms” procedures.
- Manage and maintain data integrity and update accordingly where necessary.
- Provide input and/or develop other processes to manage utilisation more efficiently.
- Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
- Regularly review all approved claims and ensure that all are settled according to correct tariffs and procedures.
- Supply all monthly management reports.
- Any other duties as assigned by the company from time to time.

**Job Types**: Full-time, Permanent

**Salary**: R35,000.00 - R40,000.00 per month

Ability to commute/relocate:

- Johannesburg, Gauteng: Reliably commute or planning to relocate before starting work (preferred)