Case Manager: Disease Management

ROLE PURPOSE

Case Manager is responsible for developing and implementing intensive multifaceted risk management interventions on a patient-specific basis with the purpose of preventing or reducing the medical schemes’ exposure to potentially high-cost members (in/out of hospital) who have been identified and risk stratified through claims analyses and clinical criteria.

Key Areas of Responsibility
- Use prepared lists of potentially high-risk patients, identified and stratified according to the level of risk, to prioritize and schedule risk management interventions.
- Further provides hospital utilisation management, education/training, and other clinically based activities as assigned, to coordinate care between the medical scheme/managed care organisation, members, providers and the community
- Ensure that all risk management interventions are patient-specific.
- Perform desk research to analyze the patient’s medical profile and claiming behavior to develop possible action plans to ensure that the patient is receiving the level and extent of care necessary for optimal management of his/her condition(s), possible action plans for improving patient adherence to treatment and possible action plans regarding lifestyle measures required to assist in mitigating the clinical risk.
- Engagement telephonically with patients to agree on strategies and specific, detailed action plans to improve the patient’s medical prognosis and optimal disease control.
- Identify areas where the member requires education and support and provide such.
- Engage with the third-party Managed Care Partners and Medical Providers to request specific health information to provide an update of a member's healthcare status and facilitate registration on the appropriate programs and authorization of care baskets.
- Set achievable goals and targets for the member to achieve i.e. visit their doctor every 6 months, have specific investigations performed at scheduled dates, lose a specified number of kilograms in a defined time period, reduce their blood pressure to 120/80, reduce their HbA1c to a specific level by a certain date, etc.
- Ensure that the member understands how to take their medicines and the need to remain adherent to their treatment.
- Help the patient make any arrangements necessary to receive optimal care and to adhere to their treatment plan and schedule.
- Communicate with the patient’s provider when necessary to coordinate care.
- Identify if the patient needs to be referred to specialist care, or have a second opinion, and assist in facilitating or arranging this.
- Arrange for patients to join support groups, enroll on the Scheme’s exercise program, dietitian program, etc., as the case may be.
- Monitor and track adherence to the agreed action plan, per patient, through claims analyses and ongoing patient engagement.
- Engage telephonically with every identified patient at least once a month to ensure adherence to action plans.
- Engage and collaborate with the clinical team for support and advice where required
- Perform site visits, where required, for high-cost patients in hospital to contain costs and coordinate and arranging cost-effective care in collaboration with the treating Doctor and facilitate discharge planning.
- Arranges for the member to be transferred to an alternative facility when on-going care is required. - Refers patients to Disease Management, where appropriate, during a hospital admission
- Monitor and record all patient interactions and action plan goals to measure the success of the interventions.
- Produce reports (statistics) to demonstrate patient progress, patient outcomes, and pre-and post-intervention outcomes.
- This person will be responsible to effectively communicate and deliver an uncompromising quality of service to all internal and external customers by ensuring that all clinical updates and coding are of the highest standard.
- Ensure adherence to Scheme Rules on all authorisations and clinical updates where applicable.
- Assist with Health Risk Management Monitoring & Management of hospital re-admissions
- Compile & submit detailed reports to the Scheme on costs and patient’s progress
- Support the Clinical Manager and HOD on any projects related to risk management.
- Meet the required daily targets and daily operational delivery within the Clinical Risk Division according to set Service Level Agreements (SLA’s) and the Performance Contract.
- Develop and maintain a general clinical understanding of Tariff coding, ICD, CPT, SAMA, RPL and National Pharmaceutical Product Interface (NAPPI) codes, and how these affect clinical billing rules.
- Assist with the review of policies, protocols, tariffs, NAPPI codes from a clinical and financial position.
- Provide the Medical Advisor with supporting documents for motivation for additional services payments on special cases.
- Attend to complaints, queries, and escalations.
- Monitor outputs and results to inform process effi