Case Manager: HRM MMH250416-9

Role Purpose

Ensure comprehensive clinical risk management training, mentoring, and skills development, aligning business processes and system capabilities to optimise service delivery and achieve departmental and individual objectives. Ensure that stakeholders are given the correct information within the Clinical Governance function. Provide enhancement and management of a cost-effective Managed Health Care project with the objective of promoting rational utilisation of Private Hospital facilities and containing associated costs generated by these services. To oversee the clinical risk management, technical training, mentoring, and ensuring alignment between business processes and service delivery objectives, whilst maintaining quality assurance and addressing skill gaps within the team.

Requirements

• Matric
• Registered with SANC registration is mandatory.
• Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife) is advantageous.
• Enrolled Nurse with strong traceable Health Risk Management experience.
• Minimum of 3 years clinical experience
• Experience in private institutions would be advantageous.
• Minimum 3 years' experience in managed health care industry is advantageous.
• ICU trained or experience would be advantageous.
• Strong knowledge of PMB legislation, Clinical Coding (ICD 10, CPT & NHRPL), hospital and doctor's billing guidelines is highly advantageous.

Duties and Responsibilities

• Manage quality and cost of clinical and medical care by liaising with members and providers and manage the reduction of recurring costly events and medicine spend.
• Ensure discharge planning is done and arrange post hospital care where necessary.
• Educate and guide all members regarding health care and their benefits.
• Develop, implement and communicate the practice and/or the clinical guidelines for cost effective care.
• Authorise appropriate and cost effective medical care and treatment.
• Ensure the consistent and correct application of exclusions.
• Adhere to policies and procedures and take corrective action where necessary.
• Adhere to organisational best practice and legislative requirements.
• Take ownership of escalated and unresolved queries and ensure they are resolved timeously and effectively.
• Manage the problem until resolution, updating the incident detail with any status updates.
• Ensure the effective, accurate and timeous completion of relevant documentation accompanying transactions.
• Manage cost of an in or out-patient episode by implementing appropriate policies and guidelines.
• Identify financial and business risks to the company and escalate accordingly.
• Provide clients with in-depth product information.
• Communicate with providers to improve the cost efficiencies of health care delivery.
• Provide clear communication to all parties involved in an investigation with regards to the outcomes and process.
• Ensure Service Level Agreements are met and exceeded.
• Engage in effective communication and delivery according to Service Level Agreements.
• Adhere to all procedures and processes to improve service delivery.
• Drive and support effective teamwork within the department.
• Engage in appropriate training interventions to promote own professional development.
• Ensure to demonstrate the company's values on a daily basis.
• Contribute to process development by identifying trends in the health industry.
• Continuously monitor and adhere to turnaround times and quality standards.
• Resolve issues speedily to enhance client service delivery.
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.
• Provide regular reports on delivery of services against agreed service level agreements and in terms of overall client targets.
• Provide authoritative expertise and advice to clients and stakeholders.
• Build and maintain relationships with clients and internal and external stakeholders.
• Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments.
• Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed.
• Make recommendations to improve client service and fair treatment of clients within area of responsibility.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
• Take ownership for driving career development.
• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
• Identify solutions to enhance cost effectiveness and increase operational efficiency.
• Implement and provide input into governance processes, systems and legislation within area of specialisation.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes.
• Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.