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Case Manager: HRM

Vacancy Details

Reference No.

SP3-5996

Synopsis

Provide enhancement and management of a cost-effective Managed Health Care project with the objective of promoting rational utilisation of Hospital facilities and containing associated costs generated by these services.

Description

  • Manage quality and cost of clinical and medical care by liaising with members and providers and manage the reduction of recurring costly events and medicine spend.
  • Ensure discharge planning is done and arrange post hospital care where necessary.
  • Educate and guide all members regarding health care and their benefits.
  • Develop, implement and communicate the practice and/or the clinical guidelines for cost effective care.
  • Authorise appropriate and cost effective medical 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 practice and legislative requirements.
  • Take ownership of escalated and unresolved queries and ensure they are resolved timeously and effectively.
  • 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.
  • Manage 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.
  • Provide clients with in-depth product information.
  • Communicate with providers to improve the cost efficiencies of health care delivery.
  • Provide clear communication to all parties involved in an investigation with regards 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
  • 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.
  • Contribute to process development by identifying trends in the health industry.
  • Continuously monitor and adhere to turnaround times and quality standards.
  • Resolve issues speedily to enhance client service delivery
  • Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
  • Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes
  • Provide regular reports on delivery of services against agreed service level agreements and in terms of overall client targets.
  • Provide authoritative, expertise and advice to clients and stakeholders
  • Build and maintain relationships with clients and internal and external stakeholders
  • Contribute to the process of negotiating objective and realistic service level agreements, monitor appropriateness and recommend adjustments
  • Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed
  • Make recommendations to improve client service and fair treatment of clients within area of responsibility
  • Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service
  • Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
  • Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.
  • Positively influence and manage change and offer specialist support where required.
  • Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
  • Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
  • Take ownership for driving career development
  • Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
  • Identify solutions to enhance cost effectiveness and increase operational efficiency.
  • Implement and provide input into governance processes, systems and legislation within area of specialisation.
  • Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes
  • Provide input into the risk identification processes development and communicate recommendations in the appropriate forum

Requirements

  • Matric
  • Registered Nurse with Degree or Diploma (General, Psychiatric and Midwife.)
  • Current registration with SANC, on application
  • Minimum of 3 years clinical experience
  • Experience in private institutions would be advantageous
  • Minimum 3 years' experience in managed health care industry
  • ICU trained or experience would be advantageous
  • Strong knowledge of PMB legislation, Clinical Coding (ICD 10, CPT & NHRPL), hospital and doctor's billing guidelines, is highly advantageous

What competencies you'll require

  • Business Acumen
  • Client/ Stakeholder Commitment
  • Drive for Results
  • Leads Change and Innovation
  • Collaboration
  • Impact and Influence
  • Self-Awareness and Insight
  • Diversity and Inclusiveness

Kindly note that if you havent received feedback within 3 weeks of submitting your application, consider it as unsuccessful

Position Type

Permanent

Work Level

Management

Salary

Market Related

Industry

Pharmaceutical And Medical/Healthcare

Salary Type

Annually

Package

Cost To Company

Affirmative Action

No

Geographic Location

Kwazulu Natal - Durban