Case Manager - Clinical Risk Management

SUMMARY:
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POSITION INFO:

OUR BLUE CHIP CLIENT WHO OPERATES IN THE FINANCIAL, INSURANCE & HEALTHCARE WELLNESS SPACE FOR INDIVIDUALS, FAMILIES AND BUSINESSES; IS CURRENTLY LOOKING TO EMPLOY A CASE MANAGER (CLINICAL RISK MANAGEMENT).

THIS POSITION WILL BE BASED IN RUSTENBURG.

Purpose of the position:

• To assist in the enhancement and management of a cost-effective Managed Health Care with the objective of promoting rational utilisation of Health Care facilities and containing associated costs generated by these services. 

 

Responsibilities:

• Manage quality and cost of clinical and medical care by liaising with members and providers and manage the reduction of recurring costly events and medicine spend.
• Communicate effectively with providers to improve the cost efficiencies of health care delivery.
• Ensure discharge planning is done and arrange post hospital care where necessary.
• Educate and guide all members regarding health care and their benefits.
• Ensure appropriate hospital benefit utilisation through tight management of all admissions, subject to scheme protocols and case management guidelines.
• Authorise appropriate and cost-effective surgical care and treatment.
• Engage in weekly hospital visits - focusing on Rustenburg and Brits but with visits to Gauteng hospitals as needed - to build stakeholder relationships, proactively resolve queries, and increase visibility to members.
• Engage in weekly client centre visits to build stakeholder relationships.
• Visit various providers in North West and Gauteng Provinces to build relationships, enhance communication and ensure compliance.
• Provide clinical support to the pre-authorisation and clinical auditing teams as required.
• Ensure the consistent and correct application of exclusions.
• Adhere to policies and procedures and take corrective action where necessary.
• Adhere to organisational best practice and legislative requirements.
• Manage cost of an in or out-patient episode by implementing appropriate policies and guidelines.
• Identify financial and business risks to the company and escalate accordingly.
• Take ownership of escalated and unresolved queries and ensure timeous resolution.
• Manage complex / problematic cases until resolution, updating the incident detail with any status updates.
• Provide clear communication with regards to the outcomes and process.
• Communicate with providers to improve the cost efficiencies of health care delivery.
• Engage in effective communication and delivery according to Service Level Agreements.
• Adhere to all procedures and processes to improve service delivery.
• Drive and support effective teamwork within the department.
• Engage in appropriate training interventions to promote own professional development.
• Ensure to demonstrate the company''s values daily.

 

Requirements:

• Minimum of 4 years clinical experience within the Healthcare industry
• Experience in specialised hospital units an advantage
• Experience in a Managed Care / Hospital Risk Management environment
• ICD-10 coding certification an advantage
• Proficient in English and another official South African language
• MS Office Suite (Word, Excel) competence
• Knowledge of Medical Schemes Act and PMB legislation
• Good understanding of the medical aid industry i.e. trends, competitors, legislation
• Own insured vehicle and valid driving licence
• Matric/Grade 12
• Nursing Diploma or Degree
• Registered with SANC (South African Nursing Council)

 

Please consider your application unsuccessful should you not receive a response within 2 weeks of applying.

 

NB! This job is now closed. You can apply for other jobs by uploading your CV.

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