|Location||Johannesburg, Johannesburg, South Africa|
A vacancy exists for a Specialised Case Manager based at Life Flora Hospital reporting to the Patient Services Manager. The successful candidate will be responsible for the financial and clinical administrative risks pertaining to patients and units. This person will be responsible to effectively communicate and deliver an uncompromising quality of service to all internal and external customers by ensuring that all clinical updates and coding are of the highest standard for all specialised cases.
Conduct ICU rounds and ensure the accurate complete collection of clinical data from patient files and liaisons with nursing staff and attending clinicians
Update accurate clinical information to justify length of stay (LOS) and level of care (LOC) to medical aid funds or their assigned managed care organisations.
Update and provide the necessary information to funders regarding high value (HV) items, limited benefits and protocols as defined by managed care organisations.
Communicate funder requirements and responses to attending clinicians and patients where necessary and ensure compliance with industry standards.
Ensure effective management of real time and manual messaging including requests, responses, rejections and submissions
Ensure the accurate submission of accounts to funders
Ensure the correct application and correct interpretation of funder RSRT contracts.
Ensure the correct application and correct interpretation of funder FFS claims
Action and close off short payment queries associated with assigned responsibilities.
Report RSRT risks identified to manager
Adherence to patient services escalation processes
Drive adherence to customer service standards
Drive adherence to AMI compliance
Foster and maintain healthy relationships with all internal and external stakeholders
Qualified Registered Nurse with SANC registration or experience in Intensive Nursing Science
Clinical Coding experience of at least one year and / qualification in clinical coding (ICD 10 and CPT coding).
Case management experience.
Knowledge of clinical terminology and anatomy, funder rules, co-payments and exclusions
Working knowledge of COID
Understanding of business and change management principles
Problem-solving, analysis and judgement
Verbal & written communication and presentation
Drive & energy
Interested candidates can send their CV