Case Manager

Unity Health; Gauteng; On-site; ZAR 200 000 - 300 000; Full time

Job summary

A healthcare provider based in South Africa is seeking a Case Manager to handle incoming calls regarding authorisations and manage clinical risk. The ideal candidate will have a nursing diploma and 2-3 years of relevant experience, with strong communication and analytical skills. Attention to detail and proficiency in MS Office are essential for this role.

Qualifications

• At least 2-3 years' experience in a similar role.
• Experience with MIP Application System an advantage.
• Sound understanding of the South African Health Industry.

Responsibilities

• Responsible for incoming calls from Hospital Case Managers for authorisations.
• Manage hospital case management and follow-up treatment.
• Ensure compliance to agreed SLA's in customer service.

Skills

Excellent oral and written communication skills

Excellent analytical skills

Customer centric attitude

Computer literate – MS Office suite

Ability to liaise with external parties

Education

Registered Nursing diploma

Matric

Job description

Case Manager – Unity Health

Unity Health is a well‑established primary healthcare provider in the South African market. Our mission is to offer primary healthcare insurance solutions to the vast majority of South Africans who are unable to afford medical scheme coverage.

Qualifications

• Matric
• Registered Nursing diploma
• Valid membership of SANCRE5 (advantageous)

Skills and Experience

• At least 2-3 years' experience in a similar role
• Experience with MIP Application System an advantage
• Sound understanding of the South African Health Industry, benefits, etc.
• ICD codes, modifiers and RPL tariff knowledge and understanding
• Ability to liaise with external parties – clinicians and members
• Ability to work within an established team
• Excellent oral and written communication skills
• Customer centric attitude
• Excellent analytical skills and pays attention to detail
• Computer literate – MS Office suite (Word, Excel)
• Good understanding of claims risk profiling
• Experience in claims auditing

Scope of Responsibility

• Responsible for incoming calls from Hospital Case Managers relating to authorisations for procedures in hospitals, casualty, doctors, or dental providers' rooms
• Hospital case management from issuing a pre‑authorisation letter to final discharge and any follow‑up treatment where required
• Manage clinical risk by promoting sound principles and strategies to decrease claims over utilisation
• Pre‑authorisation of GP visits per benefit option rules
• Classify and prioritise risks based on the frequency of member visits to a provider
• Ensure efficient Customer Service and compliance to agreed SLA's
• Follow up with healthcare practitioners and members who may be over utilising
• Manage and maintain data integrity and update accordingly where necessary
• Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained
• Weekly review of all approved claims and ensure that all claims are settled according to correct tariffs and procedures
• Ensure that all calls and cases are fully and clearly recorded on the MIP system
• Supply all monthly management reports on cases and general case management processes and initiatives
• Any other duties as assigned by your supervisor from time to time