Case Manager: HRM MMH260917-11

Momentum; Durban; On-site; ZAR 600,000 - 900,000; Full time

Job summary

Momentum in Durban seeks a senior nurse responsible for clinical risk management training, mentoring and ensuring alignment between clinical processes and service delivery. The role focuses on governance, cost-effective care and quality assurance with strong PMB compliance.

The position requires SANC registration, 3+ years of clinical experience and exposure to managed health care settings. ICU exposure is advantageous, with a focus on continuous improvement and stakeholder communication.

Qualifications

• Matric or equivalent qualification.
• SANC registration mandatory.
• Enrolled Nurse with strong Health Risk Management experience.
• Minimum of 3 years clinical experience.
• Experience in private institutions would be advantageous.
• Minimum 3 years' experience in the managed health care industry is advantageous.
• ICU trained or experienced would be advantageous.
• Strong knowledge of PMB legislation and hospital/doctor billing guidelines.

Responsibilities

• Manage the quality and cost of clinical and medical care by liaising with members and providers.
• 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 clinical guidelines for cost-effective care.
• Authorize appropriate and cost-effective medical care and treatment.
• Ensure correct application of exclusions and adherence to policies and procedures.
• Escalate unresolved policy and governance compliance issues.

Skills

Health Risk Management

Clinical governance

Discharge planning

PMB legislation knowledge

Education

Nursing Diploma or Degree (General/ Psychiatric/ Midwife)

Matric

Tools

Clinical Coding (ICD10, CPT & NHRPL)

Job description

Role Purpose

Ensure comprehensive clinical risk management training, mentoring, and skills development, aligning business processes and system capabilities to optimize 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 utilization of Private Hospital facilities and containing associated costs generated by these services.

To oversee 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
• Registering 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 adventageous
• Minimum 3 years' experience in the managed health care industry is adventageous.
• ICU trained or experience would be adventageous.
• Strong knowledge of PMB legislation, Clinical Coding (ICD10, CPT & NHRPL), hospital and doctor’s billing guidelines is highly advantageous.

Duties and Responsibilities

• Manage the 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.
• Authorize 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 organizational best practice and legislative requirement.
• Take ownership of escalated and unresolved queries and ensure they are resolved timeously and effectively.
• Manage the problem until resolution, updating the incident details with any status updates.
• Ensure the effective, accurate and timeous completion of relevant documentation accompanying transactions
• Manage the cost of an in or out-patient episode by implementing appropriate policies and guidelines
• Identify financial and business risks to the company and assess 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 you 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 standard.
• 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
• Build and maintain relationships with clients and internal and external
• 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 specialization.
• 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
• Take ownership for driving career development.
• Contribute to the development of area specific budgets to minimize 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 specialization
• 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.

As an applicant, please verify the legitimacy of this job advert on our company career page.-346021296