Our client in the healthcare industry is currently looking to employ an experienced Case Manager : Managed Health Care. (Equity candidates only)
ROLE PURPOSE:
- To assist in the enhancement and management of a cost-effective Managed Health Care with the objective of promoting rational utilisation of Health Care facilities and containing associated costs generated by these services.
WHAT YOU’RE GOING TO DO:
- Review of in-hospital patients for appropriateness of care and length of stay.
- Liaise with the service provider on the clinical update
- Discharge planning for in-hospital patients to ensure ongoing support and care post discharge
- Communicate with the medical advisor on complex cases
- Ensure efficiency of the admitting visit through regular hospital visits of in-patients
- Drive patient advocacy by coordinating in and post hospital care where necessary
- Educate and guide all members regarding health care and their benefits
- Develop, implement and communicate the practice and/or the clinical guidelines for cost effective care
- Authorise appropriate and cost effective surgical care and treatment
- Ensure the consistent and correct application of exclusions
- Adhere to policies and procedures and take corrective action where necessary
- Adhere to organisational best practice and legislative requirements
- Take ownership of escalated and unresolved queries and ensure they are resolved timeously
- Manage the problem until resolution, updating the incident detail with any status updates
- Ensure the effective, accurate and timeous completion of relevant documentation accompanying transactions
- Communicate with providers to improve the cost efficiencies of health care delivery
- Provide clear communication with regards to the outcomes and process
- Ensure Service Level Agreements are met and exceeded
- Engage in effective communication and delivery according to Service Level Agreements
- Adhere to all procedures and processes to improve service delivery
- Manage cost of an in or out-patient episode by implementing appropriate policies and guidelines
- Identify financial and business risks to the company and escalate accordingly
- Drive and support effective teamwork within the department
- Engage in appropriate training interventions to promote own professional development
- Ensure to demonstrate the company’s values on a daily basis
- Collaborate with the existing in-hospital case managers and care coordinators to ensure improved clinical quality outcomes
- Collaborate with Disease Management team in referral and management of High Risk beneficiaries
WHAT COMPETENCIES YOU’LL REQUIRE:
- Telephone etiquette and Communication – verbal and written
- Accountability
- Planning and organising
- Problem solving
- Time management
- Attention to detail
- Relationship building and interpersonal understanding
- Customer orientation and results orientation
- Empathy
- Teamwork and cooperation
- Responsibility and ownership
- Business administration skills
EXPERIENCE AND QUALIFICATIONS:
- Matric
- Nursing Diploma or Degree
- Minimum of 2 years clinical experience within the private healthcare industry
- Registered with SANC (South African Nursing Council)
- Good understanding of the medical aid industry i.e. trends, competitors, legislation
- Previous experience in a Managed Care environment required
- Fully computer literate
- Knowledge of Clinical coding; ICD, NRPL and CPT
Please consider your application unsuccessful should you not receive a response within 2 weeks of applying.