Key Responsibilities: Process: Ensure healthcare services are accounted for by liaising with relevant personnel for authorisations and ensuring compliance with case management procedures, standards, and protocols. Plan, coordinate, and execute clinical coding according to relevant standards and protocols. Ensure accurate, appropriate, and complete diagnostic and procedural coding of all patient records. Communicate consistently with Funders (Medical Aids, COID, Government, RAF, DOL, etc.) and provide clinical information to update Length of Stay (LOS), Level of Care (LOC), formulary utilisation, assistive devices/prostheses, diagnostic interventions, therapy intervention, and procedural interventions. Consult regularly with relevant healthcare providers regarding patient treatment. Maintain the clinical status of patients in accordance with Funder requirements throughout the case management process. Correctly categorise and manage patient accounts to facilitate reimbursement by Funders. Finalise cases promptly to ensure timely reimbursement. Minimise financial risk by effectively managing patient care. Follow established escalation processes for payment declines by Funders. Meet targets for Work In Progress (WIP) and Discharged Not Yet Billed (DNYB). Stakeholder Management: Build professional, long-term relationships with Funders and other stakeholders. Investigate and understand the needs of Funders, healthcare providers, and Patients to deliver quality service. Ensure accurate service knowledge and advice and keep stakeholders informed of products and service options. Resolve stakeholder queries and complaints promptly, taking ownership of case management and reimbursement issues. People: Manage oneself and contribute as a team player. Resolve conflicts and address complaints or concerns. Participate in activities for personal development and knowledge transfer among peers through coding information-sharing sessions. Finance: Monitor costs to achieve efficiencies and reduce waste. Escalate potential risks that may lead to increased costs or financial losses. Maintain accurate records of patient care for reimbursement. Maximise revenue by applying clinical judgment to LOS, LOC, formulary utilisation, assistive devices/prostheses, diagnostic interventions, therapy intervention, and procedural interventions. Liaise with the Billing department regarding the conversion of medical aid to cash patients. Ensure financial and case management documentation supports accurate record-keeping and future requirements. Reporting: Ensure complete, timely, and accurate reporting with appropriate levels of escalation. Use systems optimally for data management. Provide feedback and progress reports to stakeholders. Adhere to statutory standards, policies, and procedures to ensure compliance. Knowledge and Skills: Coding standards and protocols Core specialities in the case management process Private healthcare operations Computer literacy IDC and CPT coding Conflict management Diagnostic-related groupers Experience Required: 3-5 years experience in case management Registration: Relevant professional registration (e.g., South African Nursing Council, ) Key Stakeholders: Internal: Billings Department, Medical Practitioners, Financial Managers External: Funders/Medical Aid Schemes Impact: High on financial indicators and internal stakeholders Low on practices, policy, or strategy High on customers (direct or indirect)
