Qualification: Registered Nurse is essentialHospital Operations or Medical Aid Operations experience is requiredCoding standards and protocolsWorking knowledge of core specialties in facilityKnowledge of private health care operations will secure2-3 experience as a Case Manager within a medical aid entity or hospital environmentEnsure healthcare services rendered are accounted for:Liaise with Receptionist for authorisationsEnsure compliance to case management procedures, standards and protocolsPlan, coordinate and execute Clinical coding in accordance with relevant CHG standards and protocolsEnsure accurate, appropriate and complete diagnostic and procedural coding of all patient records in the hospitalTimeously 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 andprocedural interventions and required change in the facility.Consult daily with all relevant health care providers with regards to patient treatmentEnsure the maintenance of patients clinical status (subsequent interventions and treatments) in accordance to Funder requirements for the duration of hospitalisationEnsure the correct categorisation and management of different patient accounts to facilitatereimbursement by FundersEnsure accurate and timeous finalisation of cases to facilitate reimbursement by FundersMinimise financial risk by the effective management of patient hospitalisationFollow the established and approved escalation processes in the event of a decline of payment byFundersEnsure 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 deliveryBuild professional long-term relationships with FundersInvestigate and understand Funder, Doctors, Nurses and Patient needs to enable delivery of a qualityserviceEnsure service knowledge and advice is technically accurate and provide stakeholders with relevantinformation to keep them informed of products and service optionsEnsure timeous resolution of stakeholder queries and complaints and take ownership of casemanagement and reimbursement related issuesManage self and show up as a good team playerEnsure conflict resolution and respond to any complaints or concernIdentify and participate in planned activities that are appropriate for own developmentEnsure knowledge transfer amongst peers by participating in coding information sharing sessionsMonitor costs or expenses to achieve cost efficiencies and reduce wasteEscalate potential risks that may lead to increased costs or financial lossesMaintain accurate records of patient care and timeously submit to funders to ensure the organisationis appropriately reimbursed for all services renderedMinimise financial risk by effectively managing patient stayMaximise 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 patientsEnsure financial and case management documentation is maintained to support accurate record keeping and future requirements as per legislation and CHG standardsAdhere to reporting processesEnsure complete, timeous and accurate reporting with appropriate levels of escalation to enableeffective decision-makingUse systems optimally for data managementEnsure feedback and progress reporting to stakeholdersAdhere to statutory standards, policies and procedures within the business unit to ensure complianceat all times and take remedial action where necessary
