Case Manager | General at Life Healthcare

• A vacancy exists for a Case Manager – General based at the Life Faerie Glen, reporting to the Finance & Administration Manager. The successful candidate will be responsible for case managing the financial and clinical administrative risks pertaining to patients in general wards, high care and ICU. 

Critical Outputs
Ensuring the maximization of revenue by:

• Ensuring accuracy of coding.
• Ensuring the correct application and interpretation of RSRT’s.
• Participating in meetings and reporting losses to RSRT team and recommend corrective actions.
• Monitoring insurance verification and workflow processes.

Ensuring effective management of quality outputs by:

• Performing quality walkabouts and implement corrective measures.
• Implementing and monitoring quality improvement programs.
• Adhering to patient services escalation processes in order to achieve QMS targets.
• Monitoring Q-evaluator scores and implementing corrective measures.
• Investigating internal and external stakeholder complaints.
• Ensuring the adherence to customer service standards.

Ensuring operational excellence by:

• Monitoring submission of accurate accounts to funders.
• Updating length of stay and level of care to medical aids.
• Releasing care risk targets and submission within two days of discharge.
• Ensuring the compliance to LHC policies and managing authorizations and claim submissions, rejections and delays.
• Ensuring governance and risk management by monitoring and adhering to patient services policies and procedures.
• Ensuring compliance to service level agreements with internal and external stakeholders.
• Ensuring all billing checks are closed by the relevant function areas.

Ensuring effective management of relationships with internal/external stakeholders by:

• Building and maintaining relationships with internal stakeholders.
• Providing feedback and information on concerns or issues raised by internal stakeholders.
• Providing and facilitating training regarding RSRT contracts to the relevant internal stakeholders.
• Ensuring effective communication with external stakeholders.
• Managing escalated concerns from Care Risk Managers with external stakeholders.
• Escalating doctor non-compliance in terms of RSRT framework to RSRT meetings.
• Bill Auditing

Requirements

• Nursing qualification (i.e. RN), with at least 2-3 years’ experience in Care Risk Management within a hospital or funder environment.
• Current SANC registration.
• Knowledge of hospital patient services and case management processes.
• Knowledge and understanding of CPT & ICD coding.
• Knowledge of Funder contracts, scheme rules, exclusions and benefits.
• Understanding of private hospital industry and practices.
• Computer proficiency.
• Knowledge of Impilo systems would be an advantage.

Competencies

• Problem-solving, analysis and judgement    
• Resilience
• Engaging diversity
• Verbal & written communication and presentation
• Influencing
• Drive & energy
• Excellence orientation
• Ethical behaviour
• Building relationships
• Customer responsiveness
• Organisational awareness