Case Manager - St Augustine’s Hospital at Netcare

Role summary

• 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.

Key work output and accountabilities

• Ensure appropriate, complete and relevant diagnostic and procedural coding of all patient records within the hospital.
• Application of clinical knowledge in the risk management of patients in terms of length of stay, level of care, ICD and CPT coding, and medical aid benefits available.
• 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 with accurate coding, LOS/LOC to ensure payment on submission of the hospital invoice to the fund.
• Consult with the relevant service providers regarding the patient treatment as required.
• Compliance with all industry relevant legislative acts, regulations and circulars
• 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 and timeous communication to medical schemes by utilising the rules of engagement published in the Netcare Tariff and Billing Guidelines.
• Identify own training needs and communicate with line manager.
• Identify and ensure informal training for all relevant staff related to managed healthcare subject matter.

Skills profile
Education

• 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

• 3 years professional healthcare experience. (Essential)

Knowledge
Essential:

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

Non Managerial/ Specialist Skills

• Coaching Others* - The capacity to recognise development areas in others and support them to facilitate personal development through coaching.
• Leading and Managing Change* - The capacity to implement and support change initiatives and to provide leadership in times of uncertainty.
• Performance Development* - The ability to evaluate and develop different levels of capacity within a team to achieve set objectives.
• Taking Action -Capable of recognising the need for action, considering possible risks and taking responsibility for results.
• Actively participate as a member of a team to achieve goals.
• Active involvement in own professional development to maintain a satisfactory level of skill and knowledge.
• Availability to work OVT as required and authorised by management to ensure a healthy DNYB.
• Keep up to date with Netcare’s evolving policies and procedures.
• Decision Making - Capable of making decisions timeously and taking responsibility for the consequences.
• Managing Self - Capacity to plan, organise and control own work environment by setting appropriate priorities and achieving set objectives within a given time frame.
• Customer Focus and Service Delivery - The capacity to identify and respond to the needs of *internal and external customers.
• *Internal and external customers include patients, doctors, colleagues, suppliers, visitors, vendors and any other person that requires a relationship
• Adapting and Responding to Change - Capable of supporting and advocating change initiatives and managing own reaction to change.
• Continuous Improvement - The capacity to improve systems and processes to facilitate continuous improvement.
• Personal Work Ethic - Capacity to instil an ethic of quality and consistency in self and others.
• Building Relationships - Capacity to establish constructive and effective relationships.
• Communication - The capacity to clearly present information, either written or verbal.
• Teamwork - Capacity to cooperate with others to work towards a common goal.
• Technical Knowledge - The capacity to perform a technical function to required standards.

LEADERSHIP SKILLS

• Visioning - The ability to provide direction in terms of action towards certain future outcomes.
• Empowering - Creating conditions of willingness and participation amongst teams by providing sufficient, encouragement, information, resources and authority to make the necessary decisions to accomplish tasks.
• Energising - Having the capacity to motivate and mobilise, impart strength, vitality and enthusiasm to teams to actualise the organisation’s vision of the future.
• Designing and aligning - Ensuring the optimal alignment of employee behaviour with the organisation’s vision and values.
• Rewarding and feedback - Fostering a performance culture by creating a framework of appropriate incentives and rewards to direct and motivate the achievement of desired performance behaviours and goals.
• Team building - Creating team players and team effectiveness by using appropriate methods and a flexible interpersonal style to instil a cooperative atmosphere conducive to building a cohesive team.
• Outside orientation - Awareness of outside constituencies, emphasizing particularly the need to respond to the requirements of customers, suppliers, partners, shareholders and other interest groups, such as local communities affected by the organisation.
• Global mindset - Possessing a global frame of reference that enables one to scan the external world environment for different perspectives and to adopt successful practices. The capacity to inculcate a global mentality in others by instilling shared values and cross cultural sensitivity.
• Tenacity - The capacity and courage to persevere with one’s purpose in a persistent and determined manner despite opposition or setbacks, until the desired objective is obtained or it becomes clear that the objective is no longer attainable. Inspiring others, through active example, to have the courage of their convictions.
• Emotional intelligence - The capacity to foster trust and create an emotionally intelligent workforce whose members know themselves and know how to deal respectfully and understandingly with others. The ability to regulate and manage one’s emotions in a healthy and productive manner.
• Life balance - Articulating and modelling the importance of the need for life balance for the long term welfare of oneself and one’s employees.
• Resilience to stress - Appropriately balancing these various pressures to maintain stable performance.