To plan, coordinate and execute case management work for RAF Business in the CHG Facilities. The incumbent utilises clinical and RAF knowledge in managing RAF Business in the facilities to minimise financial risk and ensure accurate billing through comprehensive accurate coding and classification of RAF available products offered in the facilities, Authorization of these products to ensure that they will be fully reimbursed.
Minimum Requirements:
- Diploma/ Degree in General Nursing or Business-Related qualification.
- 3-5 years’ experience as RAF Case manager/Claims Adjudication Unit.
- Knowledge of ICD-10 and CPT coding.
- Knowledge of RAF Industry.
Responsibilities:
- Collaborate with the fund to ensure that the patient/claimant has access to quality healthcare services from both Acute and Rehabilitation to achieve good clinical outcomes and reintegration back into society.
- Establish a framework to enhance service delivery to patients with due attention to the Fund's financial obligations and payment processes.
- Conduct site case management through visits to different CHG facilities and Government facilities where CHG has signed MOA and share clinical updates with the fund.
- Obtain approval of care based on the Fund's treatment protocols and an appropriate referral system for specialized management.
- Establish working groups with sufficient representation from the Fund and facilities to enable good clinical governance.
- Consult daily with all relevant healthcare providers regarding patient treatment.
- Investigate and understand the needs of the Funder, Doctors, Nurses, and Patients to enable the delivery of quality service.
- Ensure service knowledge and advice are technically accurate and provide stakeholders with relevant information to keep them informed of products and service options.
- Ensure conflict resolution and respond to any complaints or concerns.
- Maximize revenue by applying clinical judgment to Length of Stay (LOS), Level of Care (LOC), formulary utilization, assistive devices/Prosthesis, diagnostic interventions, therapy interventions, and procedural interventions and required changes in the facility.
- Ensure complete, timely, and accurate reporting with appropriate levels of escalation to enable effective decision-making.
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