Senior Officer: Field Case Management at Road Accident Fund

Key Performance Areas

Decision making regarding quality of care.

• Assessment of ongoing medical problems of the injured after discharge in the home environment.
• Assessment of patient according to prescribed measurements.
• Assessment of burden of care and needs of the client.
• Monitors of quality of care issues
• Selection and monitoring clinical pathways.

Decision Making regarding collaboration.

• Facilitates collaboration of service providers with client.
• Protector of privacy and confidentiality.
• Coordination of plan of care and services.
• Facilitate caregiver’s appointments necessary for the client.
• Facilitate timely consultation with appropriate medical service providers.
• Facilitate family and clinical team communication.
• Health educator and counsellor for client and family.
• Utilization review.
• Post discharge follow-through.

Decision making regarding advocacy criteria.

• Conflict resolution expert and referee.
• Liaison between patient and care team.
• Negotiating and procuring resources and services from providers.
• Benefit analysis.
• Record keeping and documentation.
• Maintain patient confidentiality.

Decision making regarding resource utilization.

• Post discharge follow-through.
• Drug utilization review.
• Assistive devices necessary for client.
• Home alterations.
• Vehicle adaptations.
• Vocational guidance after life changing event for client.
• Placement of children in special schools.
• Back to work opportunities.

Decision making regarding legal & ethical criteria.

• Advise client of accident relatedness of his claim.
• Decide reasonableness and appropriateness of service.
• Advise whether altering homes and placing clients in rehab centres or institutions is appropriate.
• Advice regarding payment of care givers taking into account patient autonomy, informed choice, medical implications and burden of care.

Pre-authorisation of admissions.

• Arrange for hospital admission and advise patients on their benefit.

Assess medical Bills.

• Assessment of bills received and advise claimants of outcomes of bill review.

Recommend payment.

• Recommend payment of bills assessed.

Qualifications

• Bachelor’s degree or Advanced Diploma in Nursing/ Allied Health Professions or related qualification.
• Registration with the relevant Health professions council.
• Knowledge of ICD and CPT coding will be an advantage.
• Valid code 8 driving license.

Experience

• Relevant 4 years’ experience in the medical field of which 1 year is on supervisory level.
• Experience in Managed health.