Case Manager SizweHosmed
Job description
Job Purpose:
Promote optimal, quality, cost-effective health care services to members
admitted in high-cost wards, throughout the continuum of care whilst in
a healthcare facility without compromising quality of care. Ensure proper
risk management and integration of preventative healthcare services
with the objective of promoting self-management and better control of
chronic conditions
DUTIES AND RESPONSIBILITIES
- Using clinical expertise to review, monitor, and coordinate specialty services
admissions, proposed surgical procedures, utilizing approved clinical guidelines, - Reviewing clinical reports and records to determine medical necessity of proposed
procedures and coordinating services at the appropriate level of care, - Identifying and managing members in need of intensive case management and
targeted disease management initiatives, - Discussing cases with Medical Advisor regarding appropriateness of care and
alternatives, and other services to meet the - Reviewing covered benefits and alternative community and government-based
programs that may be available to member, - Monitoring patient outcomes: analyzing existing policy and providing feedback as
indicated. - Contributes to the team effort, maintains customer confidence, and identifies
potential quality issues by attending department meetings, giving and receiving feedback, - Performing other duties and assignments as requested, accomplishing related
results as needed; keeping information confidential; communicating quality of care issues. - Fostering relationships with staff at assigned hospitals to improve coordination of
care at appropriate levels. - Handling of queries effectively and efficiently
- Analyzing and review of High-cost cases for presentation to clinical operations
team - Handling of ex-gratia and CMS cases
- QUALIFICATIONS:
- Registered Nurse (with SANC) with at least 3 years Private Hospital experience
- A sound knowledge of hospital claims and charges (NHRPL)
- Sound knowledge of the Medical Schemes Act
- Sound knowledge of Prescribed Minimum Benefits.
- Good planning and prioritizing abilities
- Good analytical and problem-solving capabilities
- Good computer skills (MS Word, MS excel, PowerPoint)
- Excellent communication skills, both verbal and written
- Hi Care / ICU / theatre experience advantageous.
- Case management experience at least 2 yrs.
- Code 8 driver’s license an advantage.
Qualification & Experience
QUALIFICATIONS & EXPERIENCE:
• Diploma/Degree in Nursing or related healthcare qualification.
• Postgraduate qualifications advantageous.
• Sound knowledge of claims and charges (NHRPL)
• Sound knowledge of the Medical Schemes Act
• Sound knowledge of Prescribed Minimum Benefits.
• At least 10 years in Managed Healthcare or similar, with 5+ years in leadership roles.
• Proven expertise in Disease management, policy development, and clinical protocol implementation.