Quality Control Case Manager at Lenmed Private Hospitals

Main Focus Areas

• The incumbent will be responsible for the liaison between the patient and medical aids in order to secure payment for the hospital.

Key Performance Areas: (include but are not limited to)

• Ensuring efficient management of a very complexed department
• All IR management to be handled efficiently
• Liaise network of internal and external stakeholders to ensure that managed care of patients is maintained
• Monitor and control costs for Managed Care Organization patients
• Confirm length of stay for all Managed Care Organizations patients
• Ensure correct coding is applied for all Managed Care Organization patients
• Assisting Clinicians and all Allied facilities with account queries
• Complying with governance and risk management requirements by ensuring to patient services policies and procedures.
• Ensuring correct application of ARM agreements on patient accounts
• Building and maintaining relationships with internal stakeholders
• Ensuring effective management of real time clinical updates, including requests, responses, rejections and submissions
• Ensuring effective Communication regarding funder requirements / responses to attending clinicians and patients where necessary compliance with industry standards
• Meeting targets of monthly cash collections / maintaining of DNYB days on 5 days and below.

Post Requirements: (include but are not limited to)

• B Degree Nursing Qualification or equivalent NQF level 6
• 3 years patient care experience and Case management will be an advantage
• Previous ICU / HC Case management experience will be an advantage
• Understanding of clinical coding, funder rules – advance coding an advantage
• Nursing policies and procedures
• SAP Experience preferably
• Must be available to work overtime where required
• Advanced Computer Literacy will be an advantage
• Good communication skills
• Good customer responsiveness
• Good time management skills
• Need to be able to work under pressure