Billing Operations Cluster BOC Case Manager at Netcare

ROLE SUMMARY

• The Case Manager utilising clinical knowledge and expertise, mitigates financial risk by providing justification of the hospitalisation, encompassing level of care and length of stay to fund administrators. Case managers work collaboratively with clinical coders to provide complete clinical coding of the hospital event. The incumbent will be responsible for liaising between the patients, treating clinicians and managed care organisations to provide an accurate clinical motivation/indication of the patient’s stay in hospital.  The Case Manager will work collaboratively with the non-clinical case managers for efficient administrative processes. The Case Manager is an integral part of a team, managing and co-ordinating treatment/care, with the clinical outcomes based on quality care, disease management and cost effectiveness. (Appropriate treatment for the appropriate patient at the appropriate time). Being the advocate for the patients and where necessary, their families. The case manager works with the billings manager to achieve the billing cluster KPIs.

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.