Reference: PE002333-RW-1
Our client operating in the medical insurance space is seeking a Medical / Managed Care Claims Case Manager to join their team based in Port Elizabeth - on a 6 month fixed term contract.
Nursing Diploma or Degree essential!
EE candidate preference.
An awesome career opportunity awaits!
Duties & Responsibilities
Role Purpose
The purpose of this temporary role is to assist in the enhancement and management of cost-effective managed health care with the objective of promoting rational utilization of health care facilities and containing associated costs generated by these services for a period of 6 months only.
Requirements
- A National Senior Certificate is essential.
- It is essential to have a Nursing Diploma or Degree.
- Minimum of 2 years clinical experience within a private hospital is essential .
- The incumbent must be registered with SANC (South African Nursing Council) as a Registered Nurse.
- A certificate in ICD-10 coding is highly advantageous.
- Experience in a managed care / case management environment would be an advantage.
- MS Office / Office 365 proficiency.
- Be available to work at one of our offices based in Richmond Hill (Gqeberha), Cornubia (Durban), Bellville (Cape Town) or Centurion.
Duties - Review of in-hospital patients for appropriateness of care, length of stay and level of care.
- Liaise with the service provider on clinical updates, as well as outstanding information.
- Engage with the treating doctor(s) to ensure appropriate treatment, length of stay and level of care is rendered.
- Discharge planning for in-hospital patients to ensure ongoing support and care post discharge.
- Develop, implement and communicate the practice and/or clinical guidelines for cost effective care.
- Authorize appropriate and cost-effective surgical care and treatment.
- Ensure the consistent and correct application of exclusions.
- Adhere to policies and procedures and take corrective action where necessary.
- Adhere to organizational best practice and legislative requirements.
- Take ownership of escalated and unresolved queries and ensure they are resolved timeously.
- Manage queries until resolution and update the incident details.
- Identify financial and business risks to the company and escalate accordingly.
- Provide clinical support to non-clinical team’s if/when required.
- Drive and support effective teamwork within the department.
- Strive to demonstrate the company's values daily.
- Engage in hospital visits where needed to build stakeholder relationships, proactively resolve queries and increase visibility to members.
- Ensure the effective, accurate and timeous completion of relevant documentation and recording of interventions.
- Communicate with providers to improve the cost efficiencies of health care delivery.
- Ensure Service Level Agreements are met and exceeded.
- Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
Competencies - Effective communication skills – verbal and written.
- Accountability.
- Planning and organizing.
- Problem solving.
- Time management.
- Attention to detail.
- Interpersonal skills.
- Customer orientation.
- Results driven.
- Empathetic nature.
- Business Administration skills.
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