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.
- Perform Clinical coding in accordance with CPT and ICD requirements and as per client standards.
- Maintaining patients clinical status in accordance with funder approval requirements for the duration of hospitalisation; keeping patients informed and managing the entire hospital stays financial risk.
- Provide complete and accurate updates and discharge information.
- Receive hospital updates and assess each case based on clinical info - 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.
- Contact SMS with members.
- Follow up on active cases with service providers relating to funding levels and updates (daily).
- Interpretation of medical reports.
- Clinical decision making.
- Enrolled/Registered Nurse.
- Valid registration with SANC.
- 3 to 5 years experience within a managed healthcare or medical scheme environment.
- Valid drivers' license and own vehicle is a must. Flexibility to travel.
- 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. ICD10s, CPT4, NRPL, PMB conditions and clinical protocols.
- Extensive clinical knowledge related to all aspects of patient management.
- 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 stakeholders.
- Ability to accurately update and maintain cases information.
- Excellent telephonic and written communication skills (will be tested).
- Computer literate - MIP Application System and MS Office.
- Reporting - MS Excel basic knowledge required (will be tested).
- Proficiency in English - verbal and written.
- Verbal proficiency in additional languages will be advantageous.
- Hospital case management experience will be advantageous.
- Nursing experience in an ICU setting will be a big advantage.
- Compassionate and attentive listener - you will need to interact with the family/loved ones of members with long-stay hospital events.
- Demonstrated ability to effectively deal with emotionally charged and stressful situations.
- 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.
- Decision making skills.
- Following through on commitments.
