Hospital Case Manager

at  Kaelo

ABOUT KAELO

Kaelo provides essential healthcare solutions ensuring the physical and psychosocial well-being of all South Africans towards lasting social change.
Insurance products with limited medical benefit need close supervision for casualty and admission cases.
Job Description
The role is responsible for the authorising casualty cases with benefits telephonically or per email.
Load all hospital related cases for casualty treatment and admission into hospital.
Communicate with the clients on the benefit availability and limitation.
Review the correct level of care for admitted clients.
Negotiate with Health Care providers for clinical information.
Discharge planning for admitted patients.
This position reports to the Health Operations Manager. This position’s functions are supervised by the clinical service manager.

QUALIFICATIONS

Required

• Registered Nurse
• Degree /Diploma in Nursing
• ICU/Operation theatre trained, or experience is an advantage.
• 2 years hospital Case Management experience would be beneficial.
• Medical Aid or Insurance industry experience will be an advantage.
• Sound knowledge of ICD and CPT coding and DRG’s

Preferred

• Professional Nurse with SANC registration
• Prefer minimum of three years recent clinical experience in health, critical care and/or emergency room.
• Familiarity/experience with patient interactions on the telephone
• Strong communication and interpersonal skills

TECHNICAL SKILLS OR KNOWLEDGE

• Attention to detail.
• Health risk assessment knowledge
• Computer Literacy

KNOWLEDGE AND ABILITIES

• An ability to establish and maintain effective working relationships with patients, physicians, co-workers, staff and medical service providers.
• Strong ability to communicate effectively both verbally and in writing; thoughts are logical and clearly expressed.
• Excellent organizational abilities and documentation skills.
• Must be able to work well under stress and relate to the general public, nurses and physicians in a tactful manner.
• Must have adequate typing skills and basic computer knowledge.

• Ensuring service level agreements are met.
• Answering calls routed through for casualty or hospital treatment and admission.
• Identify exclusions from the onset of request for treatment.
• Ensure that correct benefit is utilised by member.
• Correct level of care is allocated to the correct facility.
• Latest medical guidelines are used within the available benefit.
• Reporting on cases actioned per month including savings.
• Report any clinical escalations/concerns to the clinical Review team.
• Act as a patient advocate
• Maintain all the confidentiality in clinical conditions shared with her/him.
• Review latest appliances used in hospital against the current treatment guidelines.
• Educate patients on benefit and limitations on their insurance option.
• Developing referral and treatment protocols for new or updated conditions identified.
• Discussing diagnosis with doctors, specialists and other health care providers,
• Conducting assessments of patient needs, such as mental health issues or substance abuse problems and refer to EAP where applicable.
• Providing information about treatment options, side effects, and possible complications of medications or procedures
• Assisting with monthly reporting on statistics
• Utilize all resources and guidelines at his/her disposal to effectively assess, prioritize, advise, and manage patients admitted