Talent Pool: Case Manager MMH251111-3

Role Purpose

To assist in the enhancement and management of a cost-effective managed Health Care with the objective of promoting rational utilisation of Health Care facilities and containing associated costs generated by these services.

Requirements

• Matric is essential
• Diploma in Nursing or Degree is essential
• Registered with SANC (South African Nursing Council) is Essential
• Minimum of 3-5 years of working experience within managed care or acute hospital environment is essential
• Minimum of 5 years working experience within managed care is essential
• Experience in Hospital Risk Management is desirable
• Experience in private institutions is desirable
• Good understanding of the medical aid industry i.e.trends, competitors, and legislation is essential
• Must be computer literate

Duties and Responsibilities

• Arrange post-hospital care where necessary.
• Educate and guide all members regarding health care and their benefits.
• Develop, implement and communicate the practice and/orthe clinical guidelines for cost-effective care.
• Authorise 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 organisational best practices and legislative requirements.
• Take ownership of escalated and unresolved queries and ensure they are resolved timeously.
• Manage the problem until resolution, updating the incident detail with any status updates.
• Ensure the effective, accurate, and timeous completion of relevant documentation accompanying transactions.
• Communicate with providers to improve the cost efficiencies of health care delivery.
• Provide clear communication with regard to the outcomes and process.
• Ensure Service Level Agreements are met and exceeded.
• Engage in effective communication and delivery according to Service Level Agreements.
• Adhere to all procedures and processes to improve service delivery.
• Manage the cost of an in or out-patient episode by implementing appropriate policies and guidelines.
• Identify financial and business risks to the company and escalate accordingly.
• Drive and support effective teamwork within the department.
• Engage in appropriate training interventions to promote own professional development.
• Ensure to demonstrate the company's values on a daily basis.

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