Billing Operations Cluster BOC Case Manager at Netcare

KEY WORK OUTPUT AND ACCOUNTABILITIES
DISRUPTIVE INNOVATION
Clinical Risk Management

• Apply clinical knowledge with regards to risk management of patient’s event in terms of LOS, LOC and medical aid benefits.
• Apply clinical knowledge with regards to rejection management (financial and clinical) of patients in terms of LOS, LOC and coding.
• Provide electronic clinical data to substantiate length of stay and level of care for patient’s stay in hospital.
• Ensure correct clinical coding for all patients as per clinical coding SOP. 
• Apply clinical knowledge to ensuring that materials and services are correctly classified on the system.
• Escalation of case management trends to the BOC Billings Manager for discussion in funder operational meetings.
• Monitoring the patients in progress report and ensuring that patients ward movements, bed status and level of care on the system is accurate.
• Facilitate discharge planning and movement of patients to step-down or rehab facilities.
• Efficient management of e-queries as allocated on Debtpack.
• Assist with any other duties assigned by the BOC and Billings Manager from time to time.
• Diagnostic and procedural coding
• Ensure appropriate, complete, and relevant diagnostic and procedural coding of all patient records within the cluster while the patient is in progress.
• Make use of Health Code Index.

Build and maintain stakeholder relationships

• Liaise with a network of internal and external stakeholders to ensure final billing. 
• Develop collaborative relationships to help accomplish work goals.

Effective communication

• Effective communication to medical schemes by utilising the rules of engagement published in the Netcare Tariff and Billing Guidelines.
• Effective communication, collaboration and consultation with other role players in the healthcare team.

Legal compliance

• Compliance with all industry relevant legislative acts, regulations and circulars.
• Compliance with Group Policies, Procedures and Processes.

TRANSFORMATION OF OUR SOCIETY
Training and development

• Identify own training needs and communicate with line manager.
• Identify and ensure informal training for all relevant staff related to managed healthcare subject matter.
• Formal coding training via Insight platform is compulsory. 
• Onboarding case manager Insight training to be completed.

Teamwork

• Actively participate as a member of a team to achieve goals.

Personal and professional development

• Active involvement in own professional development to maintain a satisfactory level of skill and knowledge. 
• Keep up to date with Netcare’s evolving policies and procedures.SKILLS PROFILE

EDUCATION
Required

• B Degree/Diploma Nursing qualification or equivalent NQF level 6. 
• Enrolled nursing qualification or equivalent NQF level 4.

Preferred

• Qualification in associated Healthcare Sciences or Managed Care/ Case Management.

WORK EXPERIENCE
Required

• 3 years professional healthcare experience.
• General administrative skills.
• Computer literate.

KNOWLEDGE
Required

• Clinical background.
• Understanding of a patients journey in the private healthcare environment from patient admission to final billing.