Case Manager - Specialised Units at Life Healthcare

Introduction

A vacancy exists for a Case Manager Specialised Units, based at Life Bay View Private Hospital, reporting to Susan Visser, Patient Services Manager.

The successful candidate will be responsible for the management of the financial and clinical administrative risks pertaining to patients in specialised units – intensive care units, high care units and neonatal intensive care units.

Critical Outputs

Ensuring operational excellence by: 

• Conducting ward rounds and ensuring the accurate complete collection of clinic data from patient files and liaisons  with nursing staff and attending clinicians
• Updating accurate clinical information to justify the length of stay and level of care to medical funds of specialised unit cases and where operationally required general ward cases. 
• Updating and providing the necessary information to funders regarding high-value items, limited benefits and protocols as defined by managed care organizations
• Communicating funder requirements/responses to attending clinicians and patients where necessary, and ensuring compliance with industry standards 
• Ensuring effective management of real-time and manual messaging, including requests, responses, rejections and submissions.
• Ensuring the accurate submission of accounts to funders.
• Complying with governance and risk management requirements by ensuring adherence to patient service policies and procedures
• Ensuring compliance to service level agreements with internal and external stakeholders
• Ensuring governance and risk management by monitoring and adhering to patient service policies and procedures

Ensuring effective management of revenue by:

• Ensuring the accurate and complete coding of patient accounts
• Ensuring the correct application and correct interpretation of funder RSRT contracts and FFS claims
• Reporting RSRT risks identified to the relevant manager
• Participating in meetings and reporting losses to RSRT team and recommending corrective actions

Ensuring effective management of quality outputs by:

• Adhering to patient services escalation processes and customer service standards 
• Investigating and reporting published alerts  incidents and agreeing upon appropriate action with internal and external stakeholders 
• Performing quality walkabouts and implementing corrective measures where noted
• Adhering to patient services escalation processes in order to achieve QMS targets and customer service standards 
• Investigating and reporting published alerts incidents and agreeing upon appropriate action with internal and external stakeholders 
• Implementing and monitoring quality improvement programmes
• Monitoring Q-evaluator scores and implementing corrective measures
• Ensuring the adherence to customer service standards

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

• Building and maintaining relationships with internal stakeholders
• Providing and facilitating training regarding Risk contracts
• Providing feedback and information regarding concerns or issues raised by external stakeholders
• Ensuring effective communication with external stakeholders
• Providing feedback on external stakeholders impacting on the efficiency and effectiveness of the case management process
• Escalating doctor non-compliance in terms of RSRT framework to RSRT meetings

Requirements

• Nursing qualification, Registered Nurse with at least five years’ experience on which at least 2 should be in a specialised unit 
• Knowledge of hospital patient services and case management processes
• Knowledge and understanding of CPT & ICD coding
• Understanding of clinical coding, clinical terminology and anatomy, funder rules, co-payments, exclusions and benefits
• Understanding of the private hospital industry and practices
• Experience including proven leadership, change and people management
• Understanding of business and change management principles
• Computer proficiency
• Current registration with the relevant professional/regulatory body

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
• Leading by example (Key for Managers)
• Motivating and developing people (Key for Managers)