Case Manager

Private Health Administrators (Pty) Ltd; Centurion; On-site; ZAR 420,000 - 600,000; Full time

Job summary

A health management company based in South Africa is seeking a Professional Registered Nurse to manage the spending of member funds through clinical interventions. The role requires at least 3 years of nursing experience, with a focus on patient care coordination and compliance with medical standards. Candidates should be adept in assessing treatment plans and educating members on healthcare options. This position may involve working with diverse healthcare providers to ensure optimal patient outcomes.

Qualifications

• At least 3 years of general medical and surgical nursing experience.
• ICU training or at least 1 year of ICU nursing experience.
• Minimum of 18 months of hospital pre-authorisation experience.
• At least 18 months hospital pre-authorisation experience.

Responsibilities

• Review member medical records and treatment plans.
• Coordinate care with healthcare providers.
• Evaluate clinical information for medical necessity.
• Evaluate clinical information to determine medical necessity and appropriateness of treatments.
• Approve, deny, or escalate authorisations in accordance with medical aid guidelines and protocols.
• Monitor ongoing treatment plans to ensure optimal outcomes and cost-effectiveness.
• Provide guidance and support to members on their treatment options, benefits, and preventive care.
• Educate members on managing chronic conditions and adhering to treatment plans.
• Act as the primary contact for members’ healthcare queries and concerns.
• Liaise with healthcare providers to clarify clinical information and coordinate care.
• Promote compliance with evidence-based medical guidelines.
• Facilitate referrals to specialists, rehabilitation, or support services as required.
• Maintain accurate and up-to-date records of member interactions, care plans, and authorisations.
• Compile reports on case management outcomes, cost savings, and member satisfaction.
• Ensure compliance with regulatory and organisational policies, including POPIA and medical confidentiality requirements.
• Identify trends in member utilisation and outcomes, recommending improvements in care management processes.
• Participate in training, development, and quality improvement initiatives.

Skills

Patient care management

Clinical assessment

Problem-solving

Collaboration with healthcare providers

Education

Professional Registered Nurse certification

Job description

Position Purpose: To manage the spending of member funds by means of clinical interventions and managed care protocols.

Experience: At least 3 years general medical and surgical nursing experience in the private sector. ICU training and/or at least 1 year ICU nursing experience and 1 year hospital case management experience will be advantageous. In conjunction with above, at least 18 months hospital pre-authorisation experience.

Qualifications: Professional Registered Nurse with valid up to date registration with the South African Nursing Council (MANDATORY REQUIREMENT)

KEY PERFORMANCE AREAS

Member Assessment and Care Coordination

• Review member medical records, treatment plans, and claims to assess care needs.
• Coordinate care with healthcare providers, including doctors, hospitals, and allied health professionals.
• Develop and implement individualised care plans for members with chronic conditions, complex medical needs, or high-cost cases.

Clinical Review and Authorisation

• Evaluate clinical information to determine medical necessity and appropriateness of treatments.
• Approve, deny, or escalate authorisations in accordance with medical aid guidelines and protocols.
• Monitor ongoing treatment plans to ensure optimal outcomes and cost-effectiveness.

Member Support and Education

• Provide guidance and support to members on their treatment options, benefits, and preventive care.
• Educate members on managing chronic conditions and adhering to treatment plans.
• Act as the primary contact for members’ healthcare queries and concerns.

Provider Engagement

• Liaise with healthcare providers to clarify clinical information and coordinate care.
• Promote compliance with evidence-based medical guidelines.
• Facilitate referrals to specialists, rehabilitation, or support services as required.

Reporting and Documentation

• Maintain accurate and up-to-date records of member interactions, care plans, and authorisations.
• Compile reports on case management outcomes, cost savings, and member satisfaction.
• Ensure compliance with regulatory and organisational policies, including POPIA and medical confidentiality requirements.
• Identify trends in member utilisation and outcomes, recommending improvements in care management processes.
• Participate in training, development, and quality improvement initiatives.

KEY COMPETENCIES

Knowledge

• Knowledge and application of dispensing of meds, surgical material & procedures
• Application of financial and risk assessment methodology
• Knowledge of scheme rules and contractual negotiations
• Application of clinical intervention principles
• Advise on best practice health risk solutions to relevant parties
• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedure

Skills

• Member-focused and empathetic.
• Attention to detail and accuracy in clinical assessment.
• Ability to prioritise and manage multiple cases simultaneously.
• Problem-solving and conflict resolution skills.
• Strong collaboration with internal teams and external healthcare provider
• Attention to Accuracy and Detail

Note: Company reserves the right to close the advert before specified closing date

PHA has its head office in Westville, KwaZulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.