3SixtyHealth

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(+27)11 353 0000

23 West St, Houghton Estate, Johannesburg, 2198

Careers

Case Manager SizweHosmed

Tuesday February 18th, 2025

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.

Apply Online