Medical / Managed Care Case Manager (EE)

SUMMARY:
Our client operating in the medical insurance space is seeking a Medical / Managed Care Claims Case Manager to join their team based in Port Elizabeth - on a 6 month fixed term contract.

Nursing Diploma or Degree essential!
EE candidate preference.

An awesome career opportunity awaits!

POSITION INFO:
Role Purpose
The purpose of this temporary role is to assist in the enhancement and management of cost-effective managed health care with the objective of promoting rational utilization of health care facilities and containing associated costs generated by these services for a period of 6 months only. 

Requirements

• A National Senior Certificate is essential.
• It is essential to have a Nursing Diploma or Degree.
• Minimum of 2 years clinical experience within a private hospital is essential.
• The incumbent must be registered with SANC (South African Nursing Council) as a Registered Nurse.
• A certificate in ICD-10 coding is highly advantageous.
• Experience in a managed care / case management environment would be an advantage.
• MS Office / Office 365 proficiency.
• Be available to work at one of our offices based in Richmond Hill (Gqeberha), Cornubia (Durban), Bellville (Cape Town) or Centurion.

• Review of in-hospital patients for appropriateness of care, length of stay and level of care.
• Liaise with the service provider on clinical updates, as well as outstanding information.  
• Engage with the treating doctor(s) to ensure appropriate treatment, length of stay and level of care is rendered.
• Discharge planning for in-hospital patients to ensure ongoing support and care post discharge.
• Develop, implement and communicate the practice and/or clinical guidelines for cost effective care.
• Authorize appropriate and cost-effective surgical care and treatment.
• Ensure the consistent and correct application of exclusions.
• Adhere to policies and procedures and take corrective action where necessary.
• Adhere to organizational best practice and legislative requirements.
• Take ownership of escalated and unresolved queries and ensure they are resolved timeously.
• Manage queries until resolution and update the incident details.
• Identify financial and business risks to the company and escalate accordingly.
• Provide clinical support to non-clinical team’s if/when required.
• Drive and support effective teamwork within the department.
• Strive to demonstrate the company's values daily.
• Engage in hospital visits where needed to build stakeholder relationships, proactively resolve queries and increase visibility to members.
• Ensure the effective, accurate and timeous completion of relevant documentation and recording of interventions.
• Communicate with providers to improve the cost efficiencies of health care delivery.
• Ensure Service Level Agreements are met and exceeded.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.

• Effective communication skills – verbal and written.
• Accountability.
• Planning and organizing.
• Problem solving.
• Time management.
• Attention to detail.
• Interpersonal skills.
• Customer orientation.
• Results driven.
• Empathetic nature. 
• Business Administration skills.