Medical / Managed Care Case Manager (EE)

About the position

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!

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.

Please consider your application unsuccessful if you are not contacted within two weeks of applying. 

Desired Skills:

• nurse
• clinical
• sanc
• icd
• case management
• managed care
• medical