Case Manager -Head Office, Cape Town (Metropole Managed Healthcare) at Western Cape Department of Health and Wellness

REQUIREMENTS :

• Minimum educational qualification: An Appropriate three-year health related National Diploma/Degree or equivalent registrable with the Health Professions Council of South Africa (HPCSA) or South African Nursing Council (SANC).

Experience:

• Appropriate experience in Case Management/Medical Aid Environment or Revenue Generation. Appropriate experience in ICD-10 Code assignment and the ability to link patient diagnosis with procedural codes.

Inherent requirements:

• Willingness to travel and spend long periods away from the office. A valid Code 08 Driver’s Licence. Competencies (knowledge/skills): Good knowledge of the Uniform Patient Fees Schedule (UPFS)and or other tariff structures, Managed Health Care or Hospital Information Systems and EDI (Electronic Data Interchange). Knowledge of the Medical Schemes Act 131 of 1998 and the application of Prescribed Minimum Benefit (PMB) legislation i.e. the Chronic Disease List (CDL) and Diagnostic Treatment Pairs (DTP). Ability to work with Excel spread sheets, Microsoft Word and web-based programs (medical aids).

DUTIES :

• Assist various institutions with clearing of externally funded revenue back logs related to ICD-10 code assignment, UPFS assignment and the management of PMB conditions. Assist various Hospital Fees Departments with follow-up of outstanding medical scheme and state department balances and account queries. Conduct clinical audits of patient accounts to ensure accuracy of invoices for submission to medical aids and state departments. Perform operational Case Management functions at various institutions inclusive of preauthorisation and clinical review to ensure compliance with Case Management policies and procedures. Assist with EDI rejections to ensure timeous submission of medical scheme invoices. Provide quotations to H2, H3 and Foreign patients. Assist with the implementation of departmental case management policies and procedures by providing onsite skills development and training of relevant role players in matters relating to Case management. Supervision and development of staff to ensure fully functional effective staff able to meet performance targets