Consultant Case Management

Job Advert Summary

We are seeking an experienced and highly motivated Clinical Case Manager to join our Managed Healthcare team. The successful candidate will be responsible for managing hospital authorisations, oncology and high-cost cases, utilisation management, PMB assessments, and clinical case management activities in accordance with scheme rules, clinical protocols, and regulatory requirements.

Minimum Requirements

Education

• Grade 12
• Registered nursing qualification essential.
• Intensive Nursing Science desirable.

Experience

• Computer literacy (MS Office and Medical Administration system) desirable.
• Operating Theatre or ICU experience desirable.
• Previous exposure in Renal Dialysis, Oncology and/or Psychiatric environment desirable.
• Sound knowledge of the Coding Systems: ICD10 & CPT4 Principles desirable.
• Effective conflict resolution skills and the ability to work under pressure essential.
• System knowledge (MIP, MSO or Eauth) desirable.
• Computer literacy (MS Office and Medical Administration system) desirable.
• Sound knowledge of the Medical Aid Industry, Rules & Regulations, ISO, and other related legislation

Knowledge and Skills (maximum of 10)

• Excellent business writing & communication skills with exceptional telephone etiquette
• Ability to cope with pressure
• Receptive to client complaints and queries
• Uses listening skills to identify problems
• Communicate clearly, concisely, and professionally, good listening skills; Communication skills; Telephone etiquette
• Problem solving
• Stress management skills
• Record-keeping and update skills
• Customer service orientation; Customer Relationship building skills

Duties and Responsibilities

• Ensuring successful & smooth case management process using Openscape Contact System
• Ensure adherence to Scheme Rules on all Hospital Authorisations and clinical updates
• Ensure correct allocation of facilities for our Members
• Effective handling of Internal/External Clinical Queries Communicate with members and service providers in order to address hospital utilisation matters
• Assist with Health Risk Management Monitoring & Management of hospital re-admissions
• Review claims when necessary and liaise with the claims department for reversals and reprocessing.
• Manage high-cost cases effectively and engage with treating specialists.
• Negotiate for alternative treatment methods, products, and facilities when necessary
• Manage PMB requests as per scheme directives and ensure correct applications of co-payments when applicable
• Compile & submit detailed reports to the Scheme on costs and patient’s progress
• Respond effectively to internal and external queries/problems regarding clinical matters/claims/issues relating to clinical information per request from members service providers/other employees using the system/telephone/Scheme Rules in order to address queries/problems of clients satisfactorily
• Create/monitor alternative treatment plans using physician's motivation letter/Benefit Structure/Rules of the Scheme/System/Telephone/Fax machine in order to ensure the most cost-effective treatment of cases.
• Receive/evaluate/adjudicate/authorise/capture requests from members for hospitalisation/Oncology Cases, using telephone/System/Rules of the Scheme/SOP in order to manage the hospital utilisation by members in a cost-effective manner
• Refer appeals to the Medical Advisor in order to make a final decision
• Answer/evaluate/solve queries from members/service providers concerning hospital authorisations in order to supply members/providers with accurate information
• Review/evaluate the hospital authorisations/Oncology Cases using telephone/MS Outlook/Fax machine/Rules of the Scheme/clinical knowledge in order to update pending and rejected authorisations
• Communicate with members/service providers using telephone/fax machine/MS Outlook in order to address hospital utilisation matters