Case Manager for Spinal Management Program

SUMMARY:
Actively manage the access, clinical appropriateness and risk (both financial and clinical).

POSITION INFO:

Our client in the Healthcare industry is looking for a Case Manager for Spinal Management Program to join their team. This a 12 month contact position with the possibility of becoming permanent. Our client is an accredited managed health organisation that service clients in the medical scheme industry.

Purpose of the position:

To actively manage the access, clinical appropriateness and risk (both financial and clinical) of all requests for services pertaining to back and neck pain management, spinal surgery, scans and associated healthcare services in accordance with the relevant scheme rules, clinical protocols and funding guidelines. To critically consider and propose relevant treatment alternatives that include, but are not limited to, conservative treatment options like physiotherapy. 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.

Responsibilities:

• Support the Medical Advisor and action all requests made by him/her.
• Take guidance and instruction from the Medical Advisor.
• Integrate skills and knowledge of pathophysiology, epidemiology, clinical management, and patient self-management to holistically review healthcare service and/ or authorisation requests received within the Spinal Management Programme.
• Critically review procedural clinical coding and prosthesis quotations received with requests for spinal surgery.
• Actively engage both beneficiaries and healthcare service providers.
• Case management of hospitalised patients.
• Discharge planning.
• Follow up on active cases with service providers relating to funding levels and updates (daily).
• Interpretation of medical reports.
• Clinical decision making.
• Perform comprehensive assessments for each patient and facilitate/perform follow-up in accordance with the schedule determined/agreed.
• Document all individual contacts and outcomes data in accordance with the guidelines in a timely manner.
• Call and written contact with members and Providers.
• Prepare reports/case studies as required.
• Performs other duties as assigned within the Managed Healthcare environment.

Minimum Requirements:

• Matric/Grade 12
• Registered Nurse with valid registration with SANC OR Clinical Associate (Bachelor of Clinical Medical Practice (BCMP)) with valid registration with HPCSA
• Thorough, well-grounded clinical knowledge of hospital admissions, LOS and LOC.
• Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols.
• Extensive clinical knowledge related to all aspects of holistic patient management.
• Work experience within Orthopaedic and/or Surgical theatre and wards will be advantageous.
• Solid understanding of value-based care.
• Demonstrated ability to manage a portfolio of active patient cases and to accurately update and maintain patient case information.
• Outcome focused with the ability to manage competing demands.
• Establishing and maintaining effective relationships with key stakeholders.
• Excellent telephonic and written communication skills (will be tested).
• Computer literate - MS Office Suite (intermediate) required. MIP Application System experience will be advantageous.
• Reporting – MS Excel (intermediate) required (will be tested).
• Proficiency in English – verbal and written.
• Verbal proficiency in at least two others of the national languages will be advantageous.
• Demonstrated ability to effectively deal with emotionally charged and stressful situations.
• Compassionate and attentive listener – you will need to interact with the family members.
• Self-motivator and the ability to work effectively in an independent environment.
• Strong organisational and task prioritisation skills.
• Outstanding multitasking skills.
• Ability to research and analyse information.
• High degree of accuracy and attention to detail.
• Maintaining confidentiality of information.
• Knowledge of Medical Aid policies and procedures.
• Interest in and/or knowledge of Neuro-, Orthopaedic- and Spinal surgery.
• Decision making skills.
• Following through on commitments.