Medical Services Organisation | Case Manager at Discovery Limited

Key Purpose:

•  Managing the risk relating to In hospital admissions, through the application of clinical knowledge and protocols, legislation, standard operating procedures (SOP’s), service level agreements (SLA’s) and the member’s benefit structure.

Key Outputs:

 The successful applicant will be responsible for but not limited to the following job functions:

 Assessing the case in relation to the following: 

• Members clinical history
• Members benefit structure
• Clinical Information and coding supplied
• Level of care provided
• Appropriateness of the facility
• Appropriateness of the treating doctor
• Appropriateness of treatment
• Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care
• Discharge planning by providing the member with alternatives to receive treatment (This includes Homecare, CCP etc.)

Effective and accurate communication to all stakeholders:

• Case update to the provider
• Funding decisions and benefit confirmation to the members
• Request for additional information from the treating doctor or practice manager
• Engaging with Hospital Case Managers and Doctors
• Handling escalations from Providers and internal stakeholders
• Preparing and presenting complex case to clinical review
• Trend Analysis of inefficiencies and proposals to correct
• Appropriate internal case referrals for clinical management

Operational Targets:

• SLA, e.g. TWT, DPMO 

Education and Experience:

The following requirements are essential:

• Matric
• Enrolled or Registered Nurse
• Current registration with the South African Nursing Council
• 2-years exposure to an in-hospital setting
• Experience with healthcare insurance risk management
• Experience with healthcare insurance
• 6 month’s consistent performance in current role

Skills:

• Computer and Microsoft Office skills
• Effective Communication Skills (Verbal & Written)
• Telephone Etiquette
• Active Listening Skills
• Clinical reasoning
• Critical thinking
• Problem-solving

The following requirements are advantageous:

• In Hospital Clinical CRM experience
• 1-year Managed health care experience
• 1-year Trauma / ICU exposure