Senior Officer: Hospital Case Management (Pelonomi Hospital/ Universitas) at Road Accident Fund

Purpose of the job: The Senior Officer: Hospital Case Management is accountable for the coordination of medical care for motor vehicle accident patients/claimants in Hospitals. 

Key Performance Areas

Assessment Of Injuries

• Assess extent of injuries on admitted patients.
• Daily assessment of patient according to prescribed measurements.
• Conduct daily patient scoring and data collecting.
• Monitor quality of care.
• Select and monitor clinical pathways.
• Identify patients' needs.
• Identify and record pre-existing conditions.

Facilitate Patient Care

• Facilitate multi-disciplinary patient care where appropriate.
• Facilitate timely transfers into the appropriate levels of care.
• Coordinate the admission and pre authorisations of the transfers.
• Coordinate and provide neccessary health education.
• Discharge planning and vocational guidance for the afterlife changing event for client.
• Drug utilization review.
• Proper handover to Field Case Management for continuation of care.

Patient Advocacy

• Cost Benefits analysis of the medical services.
• Liason between patient and care team to ensure common understanding and conflict resolution.
• Negotiate and procure resource services from providers.
• Ensure that patient confidentiality is maintained by all parties.

Facilitate the Accuracy and Effective Submission of Invoices 

• Ensure that accounts submitted to the fund from service providers are valid in terms of RAF guidelines and the Road Accident Fund Act.
• Assess and monitor claims invoices to curb over servicing or abuse and fraudulent claims.
• Ensure that the accounts are paid timeously, according to service level agreements.
• Ensure that services and treatments claimed for are accident related (related to the accident under consideration).
• Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided is invaluable in developing guidelines for clinical management.

Reporting 

• Compile and update Hospital Case Management reports.
• Recommend issuing of Undertaking Certificate.
• Provide a reasonableness report of patient care in preparation of the rehabilitation post discharge.

Stakeholder Management

• Communicate with all levels of stakeholders.
• Participate in relevant external RAF activities and events
• Ongoing engagements with service providers.

Qualifications

• Bachelor's Degree/ Advanced Diploma in Nursing/ Allied Health Professions or related qualification
• Registration with the relevant Health Professional Council body

Experience

• Relevant 4 years' experience in the Medical environment.
• Experience in Managed Healthcare.
• Knowledge of ICD and CPT coding will be an advantage.
• Valid code 08 driving license.

Competencies

Behavioural

• Planning, Organising and Coordinating
• Personal Mastery
• Emotional wisdom and decision making
• Ethics and Values
• Client Service Orientation                                                                        

Technical

• Core specialities in the case management process.
• Knowledge of healthcare operations.
• Ability to maintain patient confidentiality.
• Full knowledge of medical tariffs, treatment plans.
• Coding standards and protocols.
• Knowledge of PFMA to be able to analyse different requirements as per the claimants. 

NB: "RAF offers Total Employment Cost packages with no additional contributions from the Employer, successful candidates are required to structure their packages in a manner that will suit their needs."