Case Manager at Netcare

• The Case Manager utilising clinical knowledge and expertise, mitigates financial risk through comprehensive accurate coding of hospital events; as well as the justification of hospitalisation encompassing level of care and length of stay. 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 also assume responsibility for the application of clinical knowledge in the risk management of patients.

KEY WORK OUTPUT AND ACCOUNTABILITIES
OPERATIONAL EXCELLENCE

• Diagnostic and procedural coding
• Ensure appropriate, complete and relevant diagnostic and procedural coding of all patient records within the hospital.
• Application of clinical knowledge for effective ICD 10 and CCSA coding of patient Events. 
• Clinical coding of all patient events with valid ICD 10 and ccsa codes relevant to diagnosis, treatment rendered, and procedures carried out.
• Review clinical coding during patient stay in hospital.
• Risk management
• Application of clinical knowledge in the risk management of patients in terms of length of stay, level of care and medical aid benefits available.

BEST AND SAFEST PATIENT CARE

• Patient care 
• Monitor and action risk related to medical aid benefits and hospitalisation.
• Provide clinical data to substantiate length of stay and level of care.
• Accompany Managed Care Organisation Case Managers on ward rounds in the hospital, if required.
• Ensure correct clinical coding for all patients. 
• Releasing of patient accounts for billing; relating to coding, LOS/LOC to ensure submission of an accurate hospital invoice. Consult with the relevant service providers regarding the patient treatment.
• Daily clinical rounds to all patients to allow for assessment and evaluation of patient to motivate for los, loc and treatment.
• Electronic clinical updates to managed care organisation/insurance providers, to motivate for patients’ level of care and length of stay in hospital.
• Final authorisation/releasing of all discharged patient accounts for final billing after reviewing authorisation of length of stay, level of care, and Coding. Monitoring and managing costs effectively for all patients/Risk management 
• 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 facility.
• Assist with case management queries and investigations from funder, doctors and patients.
• Participate in the transition of care project as per policy.
• Reviewing and taking action on emails.
• Capturing of Risk factors
• Maintaining patient confidentiality  
• Ability to implement changes effectively.
• Manage associated administrative tasks.
• Assist with any other duties assigned by the Billings Manager from time to time.
• Legal compliance
• Compliance with all industry relevant legislative acts, regulations and circulars

STAKEHOLDER RELATIONSHIPS

• Build and maintain stakeholder relationships
• Liaise with a network of internal and external stakeholders.
• Work effectively and co-operatively with others to establish and maintain good working relationships that are mutually beneficial.
• 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.
• Provide appropriate clinical information to MCO
• Effective and timeous communication with the member of the fund when appropriate.   

GROWING WITH PASSIONATE PEOPLE

• 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.
• 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
Essential 

• B Degree/Diploma Nursing qualification or equivalent NQF level 6. 
• Enrolled nursing qualification or equivalent NQF level 4.
• Qualification in associated Healthcare sciences or Managed care/ Case management.

WORK EXPERIENCE
Essential 

• 3 years professional healthcare experience.
• Intensive Care Nursing experience is beneficial
• Previous hospital and medical scheme case management experience is beneficial
• General administrative skills
• Computer literate

KNOWLEDGE

Preferred

• Ability to develop and maintain clinical knowledge.
• Develop case management skills and expertise.
• Nursing and pharmacy policies and procedures.
• All policies and procedures related to the administrative processes within the hospital.
• Managed health care experience.
• ICD 10 and CCSA coding experience/qualification.