Case Manager

SUMMARY:
Private hospital group requires a Case Manager who is a REGISTERED NURSE and has 2 - 3 years Case Management experience within a hospital environment.

POSITION INFO:
Qualification:

• Registered Nurse is essential
• Hospital Operations experience is essential to have
• Medical Aid Operations experience is an advantage
• Coding standards and protocols
• Working knowledge of core specialties in facility
• Knowledge of private health care operations will secure
• 2-3’ experience as a Case Manager within a hospital environment is essential

Ensure healthcare services rendered are accounted for:

Liaise with Receptionist for authorisations
Ensure compliance to case management procedures, standards and protocols
Plan, coordinate and execute Clinical coding in accordance with relevant CHG standards and protocols
Ensure accurate, appropriate and complete diagnostic and procedural coding of all patient records in the hospital
Timeously and consistently communicate and follow up with Funders (Medical Aids, COID, Government, RAF, DOL, etc.)
Provide appropriate clinical information to Funders in order to update Length of Stay, Level of Care, formulary utilisation, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and procedural interventions and required change in the facility.
Consult daily with all relevant health care providers with regards to patient treatment
Ensure the maintenance of patients’ clinical status (subsequent interventions and treatments) in accordance to Funder requirements for the duration of hospitalisation
Ensure the correct categorisation and management of different patient accounts to facilitate
reimbursement by Funders
Ensure accurate and timeous finalisation of cases to facilitate reimbursement by Funders
Minimise financial risk by the effective management of patient hospitalisation
Follow the established and approved escalation processes in the event of a decline of payment by Funders
Ensure to remain in the group and facility targets of 3 days for WIP (work in progress) and DNYB (discharged not yet billed)

Build working relationships across teams and functional lines to enhance work delivery

Build professional long-term relationships with Funders
Investigate and understand Funder, Doctors, Nurses and Patient needs to enable delivery of a quality
service
Ensure service knowledge and advice is technically accurate and provide stakeholders with relevant
information to keep them informed of products and service options
Ensure timeous resolution of stakeholder queries and complaints and take ownership of case
management and reimbursement related issues

Manage self and show up as a good team player

Ensure conflict resolution and respond to any complaints or concern
Identify and participate in planned activities that are appropriate for own development
Ensure knowledge transfer amongst peers by participating in coding information sharing sessions

Monitor costs or expenses to achieve cost efficiencies and reduce waste

Escalate potential risks that may lead to increased costs or financial losses
Maintain accurate records of patient care and timeously submit to funders to ensure the organisation
is appropriately reimbursed for all services rendered
Minimise financial risk by effectively managing patient stay
Maximise revenue by applying clinical judgement to Length of Stay (LOS), Level of Care (LOC),
formulary utilisation, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and procedural interventions and required change in the facility.
Liaise with the Billing department with regards to conversion of medical aid to cash patients
Ensure financial and case management documentation is maintained to support accurate record keeping and future requirements as per legislation and CHG standards

Adhere to reporting processes

Ensure complete, timeous and accurate reporting with appropriate levels of escalation to enable
effective decision-making
Use systems optimally for data management
Ensure feedback and progress reporting to stakeholders
Adhere to statutory standards, policies and procedures within the business unit to ensure compliance
at all times and take remedial action where necessary

 

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