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
