Case Manager

H2R Africa; Pretoria; On-site; ZAR 30 000 - 60 000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Case Manager to oversee the clinical appropriateness and financial risks of hospital events. This role involves engaging with various stakeholders, performing clinical coding, and ensuring that patient care is both effective and cost-efficient. You will play a crucial part in managing chronic conditions and facilitating disease management programs, ensuring that patients receive the best possible care while balancing costs. If you are passionate about healthcare and have a knack for clinical management, this opportunity could be your next career step.

Qualifications

• Experience in clinical coding and managing healthcare services.
• Ability to assess clinical appropriateness and financial risks effectively.

Responsibilities

• Manage clinical appropriateness and financial risk of hospital events.
• Engage with stakeholders and perform clinical coding as per standards.
• Review costs and ensure care is cost-effective.

Skills

Clinical Coding (CPT, ICD)

Clinical Review

Risk Management

Stakeholder Engagement

Financial Risk Assessment

Education

Degree in Nursing or Healthcare Management

Job description

Manage the clinical appropriateness and risk (both financial and clinical) of all hospital events.

Position Info:

One of our clients in the Healthcare industry has a permanent vacancy available for a Case Manager to join their dynamic team.

Purpose of the Position:

• Actively manage the clinical appropriateness and risk (both financial and clinical) of all hospital events and related healthcare services in accordance with relevant scheme rules, clinical protocols, and funding guidelines.
• Participate in the clinical review of exceptional cases and engage with stakeholders including treating providers, hospital case managers, medical advisors, and colleagues.

Job Description:

• Perform clinical coding according to CPT and ICD requirements and client standards.
• Maintain patient’s clinical status as per funder approval requirements throughout hospitalization; keep patients informed and manage the financial risk of the entire hospital stay.
• Provide complete and accurate updates and discharge information.
• Receive hospital updates and assess each case based on clinical information, including the allocation of appropriate length of stay if clinically necessary.
• Update level of care based on clinical data.
• Review costs to ensure care is cost-effective and necessary; balance treatment costs and effectiveness to reduce re-admissions.
• Investigate and prepare cases for communication with medical advisors, schemes, providers, and members.
• Manage hospitalized members with chronic conditions registered in active disease management programs.
• Facilitate the registration of chronic and active disease conditions for hospitalized beneficiaries.
• Escalate and resolve unresolved high-cost cases.
• Identify and prepare high-cost/high-risk incidents, reporting weekly to the Clinical Specialist.
• Communicate and support Medical Advisors.
• Make calls and send written communications with members and providers.