A vacancy exists for a Case Manager Specialised based at Life Eugene Marais Hospital, reporting to Patient Services Manager.

The successful candidate will be responsible for managing the financial and clinical risks of the patient in a general ward by ensuring accurate coding, clinical updates and accounts submissions of patient hospitalization to achieve strategic objectives.

Critical Outputs
Ensuring operational excellence by:

Conducting ward rounds and ensuring the accurate complete collection of clinic data from patient files and liaisons with nursing staff and attending clinicians
Updating accurate clinical information to justify length of stay, and level of care to medical funds for specialized unit cases and, where operationally required general ward cases.
Updating and providing the necessary information to funders regarding high value items, limited benefits and protocols as defined by managed care organizations
Communicating funder requirements / responses to attending clinicians and patients where necessary, and ensuring compliance with industry standards
Ensuring effective management of real time and manual messaging, including requests, responses, rejections and submissions.
Ensuring the accurate submission of accounts to funders.
Complying with governance and risk management requirements by ensuring adherence to patient services policies and procedures
Ensuring compliance to service level agreements with internal and external stakeholders
Ensuring effective management of revenue by

Ensuring the accurate and complete coding of patient accounts
Ensuring the correct application and correct interpretation of funder RSRT contracts and FFS claims
Reporting RSRT risks identified to the relevant manager
Ensuring effective management of quality outputs by

Adhering to patient services escalation processes and customer services standards
Investigating and reporting published alerts incidents and agreeing upon appropriate action with internal and external stakeholders
Ensuring effective management of relationships with internal/external stakeholders by

Building and maintaining relationships with internal stakeholders
Providing and facilitating training regarding RSRT contracts
Providing feedback and information regarding concerns or issues raised by external stakeholders
Providing feedback on external stakeholders impacting on the efficiency and effectiveness of the case management process
Escalating doctor non-compliance in terms of RSRT framework to RSRT meetings

Requirements

Grade 12 National Senior Certificate
Diploma or degree in Nursing, Physiotherapy, Clinical Associate, Paramedics as Critical Care Assistant or Emergency Care Practitioner or any other qualification that covers Anatomy, physiology, Pathophysiology and Microbiology as foundational courses.
Nursing qualification, Registered Nurse with at least five years’ experience on which at least 2 should be in a specialized unit
Knowledge of hospital patient services and case management processes
Experience including proven leadership, change and people management
Current SANC registration
Understanding of clinical coding, clinical terminology and anatomy, funder rules, co-payments and exclusions
Working knowledge of COID
Understanding of business and change management principles
Computer proficiency

Competencies

Problem-solving, analysis and judgement
Attention to detail
Resilience
Engaging diversity
Professional and technical proficiency
Excellence orientation
Building relationships
Customer responsiveness
Organisational awareness
Action orientation
Ethical behaviour

Please send your resume/CV