CASE MANAGER HOSPITAL BENEFIT MANAGEMENT at MEDICAL AID ADMINISTRATOR

About the position

Purpose of the position
To actively manage the clinical appropriateness and risk (both financial and clinical) of all hospital events and associated healthcare services in accordance with the relevant scheme rules, clinical protocols and funding guidelines. To participate in the clinical review of exceptional cases and to engage with various stakeholders including treating providers, hospital case managers, medical advisors and colleagues.

DUTIES AND RESPONSIBILITIES

• Perform Clinical coding in accordance with CPT and ICD requirements and as per client standards
• Maintaining patient's clinical status in accordance with funder approval requirements for the duration of hospitalisation; keeping patients informed and managing the entire hospital stay's financial risk
• Provide complete and accurate updates and discharge information
• Receive hospital updates and assess each case based on clinical information - allocation of appropriate Length of Stay if clinically necessary
• Update Level of Care based on clinical information
• Review the costs to ensure cost effective and necessary care; balance cost and effectiveness of treatment to reduce re-admission
• Investigate and prepare cases for communication to the medical advisors, scheme, providers and members
• Member management of hospitalised patients with Chronic conditions who are registered on the active disease management programmes.
• Facilitation of the chronic and active disease registration of hospitalised beneficiaries who are diagnosed with one or more CDL conditions
• Escalation and resolution of unresolved high-cost cases
• Identification and preparation of high cost / high risk incidents and reported weekly to Clinical Specialist
• Discharge planning
• Communication with and support to Medical Advisors
• Call and written contact with Members and Providers
• Follow up on active cases with service providers relating to funding levels and updates (daily)
• Interpretation of medical reports
• Clinical decision making

QUALIFICATIONS

• Registered Nurse
• Must be registered with SANC
• 3 to 5 years' experience within a managed healthcare or medical scheme environment
• Thorough, well-grounded clinical knowledge of hospital admissions, Length of Stay and Level of Care
• Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures e.

• ICD10's, CPT4, NRPL, PMB conditions and clinical protocols

• Extensive clinical knowledge related to all aspects of patient

• 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
• Ability to accurately update and maintain cases
• Excellent telephonic and written communication skills (will be tested)
• Computer literate - MIP/ Medcaps Application System (knowledge/ experience will be advantageous) and MS Office Suite of Products
• Reporting - MS Excel basic knowledge required (will be tested)
• Proficiency in English - verbal and written
• Verbal proficiency in additional languages will be an advantageous
• Flexibility to tracel and a valid drivers licence is essentail
• Hospital case management experience will be advantageous
• Nursing experience within an ICU would be preferable

Desired Skills:

• Registered Nurse
• Hospital Case Management experience
• ICD and CPT coding is essential