Professional Nurse: Case Manager - Eastern cape
Introduction
Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of health capabilities.
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
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
Good understanding of the medical aid industry i.e. trends, competitors, legislation is essential
Knowledge of clinical coding; ICD, NRPL and CPT is essential
Knowledge of hospital tariffs and billing guidelines is an advantage
Minimum of 1 years' experience in a managed care environment / case management would be an advantage
MS Office proficiency
Language proficiency in at least 2 South African official languages
Duties & Responsibilities
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.
Communicate with the medical advisor on complex cases.
Drive patient advocacy by coordinating in and 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 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 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.
Drive and support effective teamwork within the department.
Strive to demonstrate the Company's values daily.
Collaborate with existing hospital case managers and care coordinators to ensure improved clinical outcomes.
Collaborate with the relevant team/s in referral and management of high-risk beneficiaries.
Competencies
Excellent telephone etiquette
Effective communication skills – verbal and written
Accountability
Planning and organising
Problem solving
Time management
Attention to detail
Interpersonal skills
Customer orientation
Results driven
Empathetic nature
Business Administration skills
