Manager: Hospital Case Management at Road Accident Fund

Key Performance Areas

Policy  review and implementation.

• Provide input into the enhancement and implementation of the case management policies and strategy and plan to ensure an alignment with short term and long-term objectives
• Manage the implementation of the case management strategy approved, including as appropriate any special tasks or projects requested by management

 Clinical care management

• Manage the clinical status of claimants in accordance with the prescribed requirements throughout the case management process
• Manage the provision of clinical assessments to ensure that admissions adhere to approved criteria
• Ensure an accurate, appropriate, and complete diagnostic and procedural coding of all claimants’ records
• Manage the assessment of medical problems of the injured and the provision of quality of care
• Identify training needs of the Senior Officers: Hospital Case Management in line with the scope of work and the changes in the processes.

 Manage the provision of patient care

• Substantiate claimant hospitalization in terms of treatment, length of stay and level of care
• Ensure that a comprehensive assessment for claimants is performed and that a follow-up in accordance with the schedule determined/ agreed is undertaken.
• Ensure the monitoring of claimant treatment recovery progress to recommend adjustments where necessary
• Ensure that the claimants focused plan of care is coordinated and communicated to ensure attention is being focused on progression towards discharge.
• Ensure that the quality of health care provided to claimant is monitored to ensure they are up to acceptable standards.
• Manage and ensure that the discharge plan for the claimant is effective and allows for continued treatment after hospital discharge
• Ensure that claimants have the necessary utilities and amenities required for complete recovery
• Provide alternative treatment options to ensure a cost effective and efficient plan of care
• Manage and fast track case management reports and recommendations relating to the issuing of Undertaking Certificate and Interim Undertaking Certificates.
• Analyze and approve the recommendations for the transfer of claimants to better facilities of care

Case management and administration

• Manage all assigned cases
• Manage the development of practice and/or clinical guidelines for cost effective care
• Intervene on clinical discussion relating to the care of MVA claimants as per the SLA and MOU
• Present cases at case rounds/ conferences to obtain multidisciplinary perspective and recommendations to achieve optimal outcomes
• Manage the provision of claimants care plan and compliance reporting
• Manage claimants case management plans, authorizations, assessment, and levels of care
• Manage the review of medical records to identify specific medical issues
• Identify financial and business risks to the Fund and escalate accordingly
• Analyze claimants care reports and make recommendation in preparation of the rehabilitation handover post discharge
• Manage high cost hospital cases and establish a forum for case managers to present high cost cases

 Manage the submission of invoices

• Validate and quality assure invoices submitted to ensure that they are aligned to the services and treatments claimed for
• Ensure financial and case management documentation supports accurate record-keeping and future requirements
• Put measures in place to safeguard against the submission of fraudulent invoices
• Manage the compliance of invoiced services from service providers and ensure validity in line with RAF Act and guidelines
• Manage timeous payment of  healthcare professionals for service rendered

Reporting

• Prepare and submit monthly and quarterly performance reports or as and when required to provide progress updates and/or inform management decisions
•  Develop functional reporting systems for case management, projects or performance reporting
•  Prepare proposals, briefings, presentations, reports, and  other documentation and provide management information both verbally and in report format.

Stakeholder management

• Engage in hospital visits where needed to build stakeholder relationships, proactively resolve queries and increase visibility to claimants
• Build productive relationship with healthcare professionals to ensure adequate referral rates to achieve budgeted occupancy level
• Build professional, long-term relationships with Funders and other stakeholders
• Ensure accurate service knowledge and advice and keep stakeholders informed of products and service options
• Manage the resolution of stakeholder queries and complaints promptly.

People Management

• Ensure the sourcing, development and retention of a high-performance team
• Manage the recruitment of the operational workforce in line with employment equity targets
• Manage staff in the department to ensure that they achieve their objectives in line with the strategic objectives of the RAF
• Manage the implementation of human capital processes and procedures to control/ regulate workplace conflict and/or institute corrective measures and consultation processes to address deviations from standards
• Allocate, direct, motivate and evaluate subordinates to help them achieve their individual goals.

Qualifications and Experience       

• Bachelor’s Degree / Advanced Diploma in a Health sciences or Medical related Degree..
• Postgraduate in Health Sciences or Medical related qualification will be an added advantage
• Registration with the relevant Health professional body
• Relevant  6-8 years’ experience in Nursing or Case Management environment of which 2 years must have been on a management/supervisory level/area of expertise
• ICU/Theatre or High cost Case Management experience will be an advantage.