North Johannesburg: Hospital Case manager / Field Case Manager

Job Summary: To plan, coordinate and execute case management work for RAF Business in the company Facilities. The incumbent utilises clinical and RAF knowledge in managing RAF Business in the facilities to minimise financial risk and ensure accurate billing through comprehensive accurate coding and classification of RAF available products offered in the facilities, Authorization of these products to ensure that they will be fully reimbursed. Minimum work experience: To collaborate with the fund in ensuring that the patient/claimant have access to quality healthcare services from both Acute and Rehabilitation to achieve good clinical outcomes and reintegration back to the society. To establish a framework in enhancing service delivery to patients with due attention to the Fund`s financial obligation and payment processes. Conduct site case management through visits to different CHG facilities and Government facilities where CHG has signed MOA with and share clinical updates with the fund. Obtaining approval of care based on the Fund`s treatment protocols and an appropriate referral system for specialized management. Establish working groups with sufficient representation from the Fund and facilities to enable good clinical governance. Consult daily with all relevant health care providers with regards to patient treatment. Investigate and understand Funder, Doctors, Nurses and Patient needs to enable delivery of a quality service Ensure service knowledge and advice is technically accurate and provide stakeholders with relevant information to keep them informed of products and service options. Ensure conflict resolution and respond to any complaints or concern. Maximize revenue by applying clinical judgement to Length of Stay (LOS), Level of Care (LOC), formulary utilization, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and procedural interventions and required change in the facility Ensure complete, timeous and accurate reporting with appropriate levels of escalation to enable effective decision-making. Diploma/ Degree in General Nursing or Business-Related qualification. 3-5 years experience as RAF Case manager/Claims Adjudication Unit. Knowledge of ICD-10 and CPT coding. Knowledge of RAF Industry