The main purpose of this position is to plan, coordinate and execute case management work at hospital level. The incumbent utilises clinical knowledge to minimise financial risk and ensure accurate billing through comprehensive accurate coding of patient care.

Detailed description

The successful candidate will be responsible for the following key performance areas:

Ensure authorizations on admissions (daily) is accurate as per SAP system.
Ensure compliance to case management procedures, standards and protocols.
Timeously and consistently communicate and follow up with Funders (Medical Aids, COID, Government, RAF, DOL, etc.).
Plan, coordinate and execute Clinical coding in accordance with relevant CHG standards and protocols.
Conduct daily case management rounds in allocated units to obtain updated clinical information from patient files. Comply with case management procedures, Medical Scheme contracts and legal aspects by utilizing available resources and systems (specifically the Case Manager Workstation on SAP).
Communicate consistently and timeously with the Medical Schemes as contractually agreed through the relevant case management channels.
Obtain Doctors letters of motivation in support of all cases where Medical Schemes request these from the hospital as part of their assessing process.
Minimize financial risk by effectively managing patient stay.
Communicate daily statistics with Billings regarding number of files with case management and with Billings, to progress these files through the system as quickly as possible and to achieve the discharge to final bill target. Resolve queries related to short payments by Medical Scheme, in conjunction with the Collections Department.
To deliver an effective case management process and facilitate the communication process between all role-players by providing accurate and timeous clinical information in order to minimize the financial risk for the company.
Adhere to statutory standards, policies and procedures within the business unit to ensure compliance at all times and take remedial action where necessary.
Maximise revenue by applying clinical judgement to Length of Stay (LOS), Level of Care (LOC).

Job requirements

Registered Nurse, Diploma in Nursing.
Certificate in Coding (advantageous).
3 to 5 years’ experience in a private hospital or medical scheme environment in a Case management capacity.
Working knowledge of ICD-10 and CPT codes.
Computer proficiency – SAP System or similar.

Legal / Professional registration required:

South African Nursing Council.

Additional requirements include:

Knowledge of private health care operations.

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