Qualification:
Registered Nurse is essential
Hospital Operations or Medical Aid Operations experience is required
Coding standards and protocols
Working knowledge of core specialties in facility
Knowledge of private health care operations will secure
2-3 experience as a Case Manager within a medical aid entity or hospital environment
Ensure healthcare services rendered are accounted for:
Liaise with Receptionist for authorisations
Ensure compliance to case management procedures, standards and protocols
Plan, coordinate and execute Clinical coding in accordance with relevant CHG standards and protocols
Ensure accurate, appropriate and complete diagnostic and procedural coding of all patient records in the hospital
Timeously and consistently communicate and follow up with Funders (Medical Aids, COID, Government, RAF, DOL, etc.)
Provide appropriate clinical information to Funders in order to update Length of Stay, Level of Care, formulary utilisation, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and
procedural interventions and required change in the facility.
Consult daily with all relevant health care providers with regards to patient treatment
Ensure the maintenance of patients clinical status (subsequent interventions and treatments) in accordance to Funder requirements for the duration of hospitalisation
Ensure the correct categorisation and management of different patient accounts to facilitate
reimbursement by Funders
Ensure accurate and timeous finalisation of cases to facilitate reimbursement by Funders
Minimise financial risk by the effective management of patient hospitalisation
Follow the established and approved escalation processes in the event of a decline of payment by
Funders
Ensure to remain in the group and facility targets of 3 days for WIP (work in progress) and DNYB (discharged not yet billed)
Build working relationships across teams and functional lines to enhance work delivery
Build professional long-term relationships with Funders
Investigate and understand Funder, Doctors, Nurses and Patient needs to enable delivery of a quality
service
Ensure service knowledge and advice is technically accurate and provide stakeholders with relevant
information to keep them informed of products and service options
Ensure timeous resolution of stakeholder queries and complaints and take ownership of case
management and reimbursement related issues
Manage self and show up as a good team player
Ensure conflict resolution and respond to any complaints or concern
Identify and participate in planned activities that are appropriate for own development
Ensure knowledge transfer amongst peers by participating in coding information sharing sessions
Monitor costs or expenses to achieve cost efficiencies and reduce waste
Escalate potential risks that may lead to increased costs or financial losses
Maintain accurate records of patient care and timeously submit to funders to ensure the organisation
is appropriately reimbursed for all services rendered
Minimise financial risk by effectively managing patient stay
Maximise revenue by applying clinical judgement to Length of Stay (LOS), Level of Care (LOC),
formulary utilisation, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and procedural interventions and required change in the facility.
Liaise with the Billing department with regards to conversion of medical aid to cash patients
Ensure financial and case management documentation is maintained to support accurate record keeping and future requirements as per legislation and CHG standards
Adhere to reporting processes
Ensure complete, timeous and accurate reporting with appropriate levels of escalation to enable
effective decision-making
Use systems optimally for data management
Ensure feedback and progress reporting to stakeholders
Adhere to statutory standards, policies and procedures within the business unit to ensure compliance
at all times and take remedial action where necessary
