Case Manager (Hospital Benefit Management)

SUMMARY:
Responsible for clinically and financially managing hospital admissions and associated healthcare

POSITION INFO:

Career Opportunity: Case Manager (Hospital Benefit Management)

Location: Pretoria (On-site)
Contract Type: Permanent
Salary: Market-related Cost to Company (includes benefits such as medical aid & pension)

Are you a clinically skilled and compassionate Registered Nurse with a deep understanding of hospital benefit management? Join our client's team, a leading accredited managed healthcare organisation, and play a key role in managing hospital events and promoting cost-effective, high-quality care for medical scheme members.

They are expanding alongside one of South Africa’s fastest-growing medical schemes and are seeking an experienced Case Manager to join their dedicated team.

Key Purpose of the Role

This role is responsible for clinically and financially managing hospital admissions and associated healthcare services. You will ensure all interventions are aligned with scheme rules, clinical protocols, and funding guidelines. You’ll be working closely with medical advisors, treating providers, and internal teams, actively engaging in clinical case reviews and risk management.

Minimum Requirements

• Registered Nurse with valid SANC registration (proof required)
• 3–5 years’ experience in managed healthcare or medical scheme environment
• In-depth clinical knowledge of hospital admissions, Length of Stay, and Level of Care
• Familiarity with healthcare legislation, ICD10, CPT4, NRPL, and PMB coding
• Strong understanding of value-based care and patient outcomes

Preferred Experience & Skills

• ICU nursing or hospital case management experience (highly advantageous)
• Knowledge of MIP/Medcaps systems and MS Office (Excel proficiency will be tested)
• Exceptional written and verbal communication skills (English essential; additional languages advantageous)
• Sound decision-making, emotional resilience, and stakeholder engagement
• Able to navigate sensitive member cases with empathy and professionalism
• Able to prioritise, multitask, and manage administrative processes efficiently

Core Responsibilities

• Perform clinical coding aligned with CPT/ICD standards and internal protocols
• Monitor hospitalised members, manage updates, and coordinate discharge planning
• Evaluate clinical updates and determine appropriate funding/Length of Stay
• Liaise with healthcare providers, members, and internal stakeholders to ensure timely updates and resolution
• Manage hospitalised members with chronic conditions, ensuring correct programme registration
• Flag and escalate high cost/high-risk cases for specialist review
• Maintain accurate case information, conduct clinical decision-making, and support provider relationships
• Provide written and telephonic feedback to all parties involved in the care cycle
• Participate in reporting and case risk reviews with Clinical Specialists

What We Offer

• A supportive and collaborative team environment
• Opportunity to work at the forefront of healthcare management
• Structured development and continuous learning opportunities
• Competitive benefits and long-term career growth potential

To Apply
Please submit your CV and certified copy of your current SANC registration. If you’re ready to make an impact in patient-centered care and managed healthcare, we look forward to receiving your application.