Case Manager

SUMMARY:
We looking for a Case Manager that will be responsible for managing patient cases from pre-admission to post-discharge, ensuring appropriate care and resource utilisation in line with clinical guidelines. The role involves liaising with hospitals, doctors, and healthcare providers to facilitate optimal care while balancing cost containment for the medical aid scheme or healthcare fund.

POSITION INFO:

Key Responsibilities:

1. Case Management:
   
   • Manage hospital admissions by reviewing the appropriateness of care and ensuring all admissions are clinically warranted.
   • Conduct pre-admission, admission, and discharge planning, including monitoring length of stay and level of care to ensure it aligns with scheme rules and clinical guidelines.
   • Coordinate with healthcare providers to ensure the most efficient and cost-effective care is delivered to patients.
2. Clinical Assessments and Authorisations:
   
   • Perform clinical assessments based on patient medical records, treatment plans, and physician reports.
   • Approve or recommend alternative care options based on medical necessity, ensuring alignment with clinical guidelines.
   • Authorise hospital admissions, procedures, and specialist treatments in line with policy and clinical protocols.
3. Collaboration with Providers:
   
   • Communicate regularly with healthcare providers (hospitals, doctors, and allied healthcare professionals) to review patient progress and treatment plans.
   • Facilitate case conferences between healthcare providers when necessary to improve patient outcomes.
   • Liaise with multi-disciplinary teams to ensure integrated patient care and support appropriate care pathways.
4. Cost and Resource Management:
   
   • Monitor and manage the cost of hospitalisation, treatment, and post-discharge care in alignment with the medical aid scheme’s financial goals.
   • Identify potential cost-saving measures while ensuring patients receive high-quality care.
   • Monitor adherence to length of stay targets, care levels, and use of hospital resources to avoid unnecessary hospital stays and over-treatment.
5. Risk and Compliance Management:
   
   • Ensure compliance with all clinical and regulatory guidelines, medical aid scheme rules, and hospital policies.
   • Identify and manage clinical risks by implementing interventions that align with the scheme's objectives.
   • Ensure accurate and timely documentation of all case management activities and maintain comprehensive records for auditing and reporting purposes.
6. Reporting and Documentation:
   
   • Prepare and maintain detailed case reports for each patient, documenting clinical interventions, hospital admissions, length of stay, and discharge planning.
   • Provide regular updates to management on key case management metrics, including costs, compliance, and patient outcomes.

Key Skills & Competencies:

• Clinical Knowledge: Deep understanding of hospital care, treatment protocols, and patient care pathways, especially in ICU, surgical, and medical ward settings.
• Decision-Making: Ability to assess clinical cases and make informed decisions about patient care and cost containment.
• Communication Skills: Excellent verbal and written communication skills for liaising with healthcare providers, patients, and medical aid administrators.
• Collaboration: Strong ability to work with multi-disciplinary teams to ensure integrated and coordinated patient care.
• Organisational Skills: Effective time management and organisational skills to manage multiple cases simultaneously.
• Analytical Skills: Ability to analyse clinical data, treatment outcomes, and resource usage to provide insights and recommendations.

Minimum Requirements:

• Education: Registered Nurse or Healthcare Professional with relevant clinical qualifications
• Professional Membership: Registered with the South African Nursing Council (SANC) or relevant professional body
• Experience: Minimum of 3-5 years of clinical experience in a hospital environment, with at least 2 years of experience in case management or managed care
• Skills: Proficiency in clinical assessments, hospital billing, and discharge planning. Understanding of healthcare systems and regulations.