Job Summary:

To deliver an effective case management process and facilitate the communication process between all role-players by providing accurate and timeous clinical information in order to minimize the financial risk for the company.

Minimum Qualifications and Experience:

• Grade 12.
• Registered Nurse, currently registered with SANC.
• Certificate in Coding (advantageous).
• 3 to 5 years’ experience in a private hospital or medical scheme environment in a Case management capacity.
• Working knowledge of ICD-10 and CPT codes.
• Computer proficiency – SAP System or similar.

Minimum Job Requirements:

• Ensure authorizations on admissions (daily) is accurate as per SAP system.
• Conduct daily case management rounds in allocated units to obtain updated clinical information from patient files. Comply with case management procedures, Medical Scheme contracts and legal aspects by utilizing available resources and systems (specifically the Case Manager Workstation on SAP).
• Communicate consistently and timeously with the Medical Schemes as contractually agreed through the relevant case management channels.
• Obtain Doctors letters of motivation in support of all cases where Medical Schemes request these from the hospital as part of their assessing process.
• Minimize financial risk by effectively managing patient stay.
• Communicate daily statistics with Billings regarding number of files with case management and with Billings, to progress these files through the system as quickly as possible and to achieve the discharge to final bill target. Resolve queries related to short payments by Medical Scheme, in conjunction with the Collections Department.