Job Description

Our client based in the north needs a case manager to coordinate and execute case management work. Utilising clinical knowledge, the incumbent minimises financial risk and ensures accurate billing through comprehensive and precise coding of patient care.Key Responsibilities:
Process:

• Ensure healthcare services are accounted for by liaising with relevant personnel for authorisations and ensuring compliance with case management procedures, standards, and protocols.
• Plan, coordinate, and execute clinical coding according to relevant standards and protocols.
• Ensure accurate, appropriate, and complete diagnostic and procedural coding of all patient records.
• Communicate consistently with Funders (Medical Aids, COID, Government, RAF, DOL, etc.) and provide clinical information to update Length of Stay (LOS), Level of Care (LOC), formulary utilisation, assistive devices/prostheses, diagnostic interventions, therapy intervention, and procedural interventions.
• Consult regularly with relevant healthcare providers regarding patient treatment.
• Maintain the clinical status of patients in accordance with Funder requirements throughout the case management process.
• Correctly categorise and manage patient accounts to facilitate reimbursement by Funders.
• Finalise cases promptly to ensure timely reimbursement.
• Minimise financial risk by effectively managing patient care.
• Follow established escalation processes for payment declines by Funders.
• Meet targets for Work In Progress (WIP) and Discharged Not Yet Billed (DNYB).

Stakeholder Management:

• Build professional, long-term relationships with Funders and other stakeholders.
• Investigate and understand the needs of Funders, healthcare providers, and Patients to deliver quality service.
• Ensure accurate service knowledge and advice and keep stakeholders informed of products and service options.
• Resolve stakeholder queries and complaints promptly, taking ownership of case management and reimbursement issues.

People:

• Manage oneself and contribute as a team player.
• Resolve conflicts and address complaints or concerns.
• Participate in activities for personal development and knowledge transfer among peers through coding information-sharing sessions.

Finance:

• Monitor costs to achieve efficiencies and reduce waste.
• Escalate potential risks that may lead to increased costs or financial losses.
• Maintain accurate records of patient care for reimbursement.
• Maximise revenue by applying clinical judgment to LOS, LOC, formulary utilisation, assistive devices/prostheses, diagnostic interventions, therapy intervention, and procedural interventions.
• Liaise with the Billing department regarding the conversion of medical aid to cash patients.
• Ensure financial and case management documentation supports accurate record-keeping and future requirements.

Reporting:

• Ensure complete, timely, and accurate reporting with appropriate levels of escalation.
• Use systems optimally for data management.
• Provide feedback and progress reports to stakeholders.
• Adhere to statutory standards, policies, and procedures to ensure compliance.

Knowledge and Skills:

• Coding standards and protocols
• Core specialities in the case management process
• Private healthcare operations
• Computer literacy
• IDC and CPT coding
• Conflict management
• Diagnostic-related groupers

Experience Required:

• 3-5 years experience in case management

Registration:

• Relevant professional registration (e.g., South African Nursing Council, )

Key Stakeholders:

• Internal: Billings Department, Medical Practitioners, Financial Managers
• External: Funders/Medical Aid Schemes

Impact:

• High on financial indicators and internal stakeholders
• Low on practices, policy, or strategy
• High on customers (direct or indirect)

Edge Executive