As the leading medical recruitment agency in South Africa, our client has an exciting opportunity for a Clinical Case Manager (Nurse) based in Nelspruit, Mpumalanga, South Africa. The Clinical Case Manager (Nurse) will be accountable for in-hospital pre-authorizations, case management, and evaluation of clinical data for high-value claims. Responsibilities include assessing, planning,implementing, monitoring, and evaluating actions to minimize risk and ensure compliance with medical aid scheme rules and protocolsResponsibilitiesManage all aspects of in-hospital cases, including high-risk cases, emergency evacuations, and in-patient transfers, in accordance with scheme rules and benefits.Conduct hospital pre-evaluations and pre-authorizations, ensuring adherence to protocols and guidelines.Optimize clinical benefits management by applying knowledge of scheme rules, protocols, length of stay, level of care, and available medical aid benefits.Implement action plans to mitigate financial risks to the scheme and negotiate tariffs and discounts with service providers.Communicate effectively with healthcare teams, hospitals, clinics, and doctors' offices regarding members' care plans and treatment protocols.Coordinate air and road evacuations from Mozambique to South Africa as needed.Conduct ongoing internal claims auditing, investigations, and monthly visits to service providers.Maintain client relationships with service providers and ensure high levels of quality and risk control.Provide daily, weekly, and monthly reporting to executive management and perform other duties as assigned.Conduct monthly group risk analyses, including billing, utilization, chronic conditions, and hospitalization assessments.Manage and oversee the performance and task management of the Clinical Benefits team, including staff support, development, and training.Requirements:Qualification in Nursing (Registered or Enrolled Nurse) with a valid SANC registrationClinical knowledge of chronic conditions and management experience in various healthcare settings.Minimum 3 - 10 years of case management experience in managed healthcare and/or hospital case management.Experience in settings relevant to medical aid and healthcare processes, with previous corporate experience.Proficiency in MS Outlook, Word, and Excel, with strong administrative and managerial skills.Fluent in Afrikaans and English. (Ability to speak Portuguese would be advantageous)Valid driver's license.Salary is market related + fully subsidized medical aidWorking hours: Mon - Fri (08h00 - 16h00)Location: Nelspruit, MpumalangaTo apply, please send your updated CV to ****** Please be advised that you will be contacted by Medipath Healthcare Recruitment within 14 days should we wish to proceed with your application. Similarly, if you are not contacted by Medipath Healthcare Recruitment, please accept your application as unsuccessful. Your CV will automatically be added to our database and we could be contacting you should a suitable position arise.
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