Hospital Case Manager

1 week ago

Paarl, South Africa Spescare (Pty) Ltd Full time

Includes the following - Other Duties may be assigned. Responsible for the case management process within the sub-acute hospital.
- Conduct ward rounds and ensure the accurate complete collection of clinic data from patient files and liaisons with nursing staff and attending clinicians.
- Update accurate clinical information to justify, length of stay (LOS) and level of care (LOC) to medical funds the assigned managed care organization.
- Update and provide the necessary information to funders regarding HV (high value) items, limited benefits and protocols as defined by managed care organizations.
- Communicate funder requirements / responses to attending clinicians and patients where necessary, and ensure compliance with industry standards.
- Ensure effective management of real time and manual messaging, including request, responses, rejections and submissions.
- Ensure the accurate submission of accounts to funders.
- Understand and ensure adherence to patient’s services policies and procedures.
- Ensure accurate and complete coding of patient accounts.
- Action and close off short payment queries associated with assigned responsibilities.
- Report RSRT risk identified to manager.
- Adherence to patient services escalation processes.
- Drive adherence to customer service standards.
- Foster and maintain healthy relationships with internal stakeholders. E. g. nursing, pharmacy and business hubs.
- Interacts with referring doctors and referring hospital staff to ensure that patients that need the service provided by the Company are referred.
- Interacts with medical schemes to ensure that authorisations are provided timeously.
- Verification of clinical coding as per policies and procedures.
- Provides support for the management of alternative fee structures.
- Liaison with doctors on further requirements when necessary.
- Continuous performance and quality management.
- Interprets and implements scheme benefit rules.
- Maintains client service principles to ensure client expectations are met.
- Auditing and final bill of all accounts.
- Pharmacy medication capturing. (Billing)
- Patient Release, discharge report to be send to relevant doctors.
- Patient Referral forms to send to Medical Aids.
- Liaise with Manager - Nursing Services regarding prioritization of work plan.
- Network with other hospitals and case managers.

**Education**:

- Matric
- Nursing background with relevant tertiary qualification.
- Registered with SANC - required.
- Knowledge of medical ICD-10 codes would be advantages.
- Valid Drivers license.

**Experience**:

- Minimum Two years Hospital case management experience in a medium to large concern.
- Clinic Manager experience would be advantageous.

**SKILLS**
- Proficient in Microsoft office (Word, Excel, Outlook)
- _ Fully bilingual._
- Good English written and verbal communication.
- _ Excellent telephone manner with an overall pleasant disposition_.
- _ Ability to be assertive when needed_.
- _ Flexible work style_.
- _ Collaborative _- able to work well with people within and outside the company

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