MAIN PURPOSE OF JOB
To coordinate the hospital case management process and facilitate the communication process between all role players by providing accurate and timeous clinical information to minimise the financial risk for the organisation.
KEY RESPONSIBILITY AREAS
Minimise financial risk by effectively managing patient stay
Ensure compliance to case management procedures, contracts and legal aspects by utilising available resources and systems
Ensure correct and timeous finalisation of cases to facilitate reimbursements from funders of claims
Consistently and timeously communicate with Funders as contractually agreed through the relevant case management channels
Ensure clinical coding standards are adhered to as per Level 3 coding guideline
Lead and manage the people in the Case Management team (if applicable)
REQUIRED EDUCATION
ESSENTIAL EDUCATION: Clinical qualification
DESIRED EDUCATION: Registered Nurse / Professional Nurse or qualified Paramedic
REQUIRED EXPERIENCE
ESSENTIAL MINIMUM EXPERIENCE: Minimum of 3 years in a clinical role
DESIRED EXPERIENCE: Experience in Theatre and or ICU; Medical aid background; Experience in private healthcare environment or experience as an ILS/ALS Paramedic
REQUIRED JOB SKILLS AND KNOWLEDGE
1. Understanding of anatomy; physiology and medical terminology
2. Funder Contracts; Medical aid requirements/narrations
3. Scientific nursing principles and process
4. Authorisation and motivation of Level of Care; Length of Stay; Clinical Coding, high-cost stock, Short Payments etc.
5. Use of electronic systems (i.e. B2B or Funder portals) for the purposes of requesting authorisations, performing case management updates and for troubleshooting)
6. Computer literacy (Microsoft Office, hospital/practice management systems)
7. Relevant aspects of applicable statutory acts (e.g. Consumer Protection Act; PMB; etc.)
8. Patient Administration policies and procedures (e.g. Patient Confidentiality; Visitation of external case managers; etc.)
9. Daily workflow; managing deviances; clinical coding; and case management processes
10. Application of clinical codes and finalisation thereof