Ensure compliance to case management procedures, standards and protocols.
Plan, coordinate and execute Clinical coding in accordance with relevant company standards and protocols.
Timeously and consistently communicate and follow up with Funders (Medical Aids, COID, Government, RAF, DOL, etc.)
Provide appropriate clinical information to Funders in order to update Length of Stay, Level of Care, formulary utilisation, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and procedural interventions and any required changes in patient treatment.
Investigate and understand Funder, Doctors, Nurses and Patient needs to enable delivery of a quality service.
Ensure timeous resolution of stakeholder queries and complaints and take ownership of case management and reimbursement related issues.
Escalate potential risks that may lead to increased costs or financial losses.
Maintain accurate records of patient care and timeously submit to funders to ensure the organisation is appropriately reimbursed for all services rendered.
Liaise with the Billing department with regards to conversion of medical aid patients to cash patients.
Adhere to statutory standards, policies and procedures within the business unit to ensure compliance at all times and take remedial action where necessary.
Diploma in Nursing
5 years’ experience as a hospital case manager
Knowledge of ICD-10 and CPT Coding
Knowledge of private health care operations
Attention to detail and ability to confirm accuracy of files