Case Manager: HRM X 5 at Momentum Metropolitan Holdings Limited

Role Purpose    
Provide enhancement and management of a cost-effective Managed Health Care project with the objective of promoting rational utilisation of Hospital facilities and containing associated costs generated by these services.

Requirements    

• Matric
• Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife.) is essential
• Current registration with SANC, on application is essential
• Minimum of 3 years clinical experience
• Experience in private institutions would be advantageous
• Minimum 3 years' experience in managed health care industry is advantageous
• ICU trained or experience would be advantageous
• Strong knowledge of PMB legislation, Clinical Coding (ICD 10, CPT & NHRPL), hospital and doctor's billing guidelines, is highly advantageous

Duties & Responsibilities    

• Manage quality and cost of clinical and medical care by liaising with members and providers and manage the reduction of recurring costly events and medicine spend.
• Ensure discharge planning is done and arrange post hospital care where necessary.
• Educate and guide all members regarding health care and their benefits.
• Develop, implement and communicate the practice and/or the clinical guidelines for cost effective care.
• Authorise appropriate and cost effective medical care and treatment.
• Ensure the consistent and correct application of exclusions.
• Adhere to policies and procedures and take corrective action where necessary.
• Adhere to organisational best practice and legislative requirements.
• Take ownership of escalated and unresolved queries and ensure they are resolved timeously and effectively.
• Manage the problem until resolution, updating the incident detail with any status updates.
• Ensure the effective, accurate and timeous completion of relevant documentation accompanying transactions.
• Manage cost of an in or out-patient episode by implementing appropriate policies and guidelines.
• Identify financial and business risks to the company and escalate accordingly.
• Provide clients with in-depth product information.
• Communicate with providers to improve the cost efficiencies of health care delivery.
• Provide clear communication to all parties involved in an investigation with regards to the outcomes and process.
• Ensure Service Level Agreements are met and exceeded.
• Engage in effective communication and delivery according to Service Level Agreements.
• Adhere to all procedures and processes to improve service delivery
• Drive and support effective teamwork within the department.
• Engage in appropriate training interventions to promote own professional development.
• Ensure to demonstrate the company's values on a daily basis.
• Contribute to process development by identifying trends in the health industry.
• Continuously monitor and adhere to turnaround times and quality standards.
• Resolve issues speedily to enhance client service delivery
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes
• Provide regular reports on delivery of services against agreed service level agreements and in terms of overall client targets.
• Provide authoritative, expertise and advice to clients and stakeholders
• Build and maintain relationships with clients and internal and external stakeholders
• Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments
• Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed
• Make recommendations to improve client service and fair treatment of clients within area of responsibility
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service
• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
• Take ownership for driving career development
• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
• Identify solutions to enhance cost effectiveness and increase operational efficiency.
• Implement and provide input into governance processes, systems and legislation within area of specialisation.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes
• Provide input into the risk identification processes development and communicate recommendations in the appropriate forum

Competencies    

• Business Acumen
• Client/ Stakeholder Commitment
• Drive for Results
• Leads Change and Innovation
• Collaboration
• Impact and Influence
• Self-Awareness and Insight
• Diversity and Inclusiveness