Case Manager

SUMMARY:
We are looking for a clinically experienced nursing professional who understands the relationship between patient care, clinical coding, medical aid administration, managed healthcare, billing and healthcare finance.

POSITION INFO:

REQUIREMENTS

• Enrolled Nurse/ Registered Nurse with valid SANC registration
• Previous nursing experience in a hospital environment
• Previous experience in Case Management, 4 - 5 years
• Strong knowledge of Clinical Coding and clinical documentation
• Knowledge and understanding of Managed Healthcare Rules of Engagement
• Experience with hospital billing and medical aid processes
• Knowledge of medical aid administration and authorisation processes
• Strong understanding of clinical terminology and anatomy
• Knowledge of ICD-10 and CPT coding
• Understanding of healthcare finance and financial processes
• Advanced computer literacy and strong ability to work with healthcare information systems
• Excellent analytical, administrative and organisational skills
• Strong communication and interpersonal skills
• Ability to interpret clinical information and apply managed healthcare guidelines
• Ability to work independently and meet deadlines
• High level of accuracy and attention to detail

KEY RESPONSIBILITIES

• Manage and coordinate patient cases throughout the hospitalisation process
• Review clinical information and patient records to ensure appropriate levels of care
• Apply Managed Healthcare Rules of Engagement when assessing and managing patient cases
• Liaise with medical schemes, managed healthcare organisations, doctors and hospital departments
• Obtain and manage medical aid authorisations
• Monitor patient length of stay and identify potential delays or risks
• Review clinical documentation for completeness and accuracy
• Apply clinical coding principles and ensure accurate coding information
• Assist with billing and account-related processes
• Identify potential billing discrepancies and ensure accurate patient accounts
• Monitor utilisation of healthcare resources
• Provide relevant clinical and financial information to medical schemes and other stakeholders
• Ensure accurate and timely documentation of case management activities
• Support effective cost management while maintaining quality patient care
• Maintain confidentiality and comply with relevant healthcare, hospital and professional standards