SmartHR (Employee Self Service)

ROLE PURPOSE Case Manager is responsible for developing and implementing intensive multifaceted risk management interventions on a patient-specific basis with the purpose of preventing or reducing the medical schemes’ exposure to potentially high-cost members (in/out of hospital) who have been identified and risk stratified through claims analyses and clinical criteria/
Key Areas of Responsibility Use prepared lists of potentially high-risk patients, identified and stratified according to the level of risk, to prioritize and schedule risk management interventions/ Further provides hospital utilisation management, education/training, and other clinically based activities as assigned, to coordinate care between the medical scheme/managed care organisation, members, providers and the community Communicates with the admitting facility to establish the clinical status of the patient/ - Communicates updates of level of care, length of stay and value to the hospital subject to the clinical guidelines and protocols of the scheme where/ Ensure that all risk management interventions are patient-specific. Perform desk research to analyze the patient’s medical profile and claiming behavior to develop possible action plans to ensure that the patient is receiving the level and extent of care necessary for optimal management of his/her condition(s), possible action plans for improving patient adherence to treatment and possible action plans regarding lifestyle measures required to assist in mitigating the clinical risk/ Engagement telephonically with patients to agree on strategies and specific, detailed action plans to improve the patient’s medical prognosis and optimal disease control. Identify areas where the member requires education and support and provide such/ Engage with the third-party Managed Care Partners and Medical Providers to request specific health information to provide an update of a member's healthcare status and facilitate registration on the appropriate programs and authorization of care baskets. Set achievable goals and targets for the member to achieve i/e/ visit their doctor every 6 months, have specific investigations performed at scheduled dates, lose a specified number of kilograms in a defined time period, reduce their blood pressure to 120/80, reduce their HbA1c to a specific level by a certain date, etc/ Ensure that the member understands how to take their medicines and the need to remain adherent to their treatment. Help the patient make any arrangements necessary to receive optimal care and to adhere to their treatment plan and schedule/ Communicate with the patient’s provider when necessary to coordinate care. Identify if the patient needs to be referred to specialist care, or have a second opinion, and assist in facilitating or arranging this/ Arrange for patients to join support groups, enroll on the Scheme’s exercise program, dietitian program, etc., as the case may be. Monitor and track adherence to the agreed action plan, per patient, through claims analyses and ongoing patient engagement/ Engage telephonically with every identified patient at least once a month to ensure adherence to action plans. Engage and collaborate with the clinical team for support and advice where required Perform site visits, where required, for high-cost patients in hospital to contain costs and coordinate and arranging cost-effective care in collaboration with the treating Doctor and facilitate discharge planning. Arranges for the member to be transferred to an alternative facility when on-going care is required/ - Refers patients to Disease Management, where appropriate, during a hospital admission Monitor and record all patient interactions and action plan goals to measure the success of the interventions. Produce reports (statistics) to demonstrate patient progress, patient outcomes, and pre-and post-intervention outcomes/ This person will be responsible to effectively communicate and deliver an uncompromising quality of service to all internal and external customers by ensuring that all clinical updates and coding are of the highest standard. Ensure adherence to Scheme Rules on all authorisations and clinical updates where applicable/ Assist with Health Risk Management Monitoring & Management of hospital re-admissions Compile & submit detailed reports to the Scheme on costs and patient’s progress Educate members on their chronic conditions via email or telephonically. Support the Clinical Manager and HOD on any projects related to risk management/ Meet the required daily targets and daily operational delivery within the Clinical Risk Division according to set Service Level Agreements (SLA’s) and the Performance Contract. Develop and maintain a general clinical understanding of Tariff coding, ICD, CPT, SAMA, RPL and National Pharmaceutical Product Interface (NAPPI) codes, and how these affect clinical billing rules/ Assist with the review of policies, protocols, tariffs, NAPPI codes from a clinical and financial position. Provide the Medical Advisor with supporting documents for motivation for additional services payments on special cases/ Attend to complaints, queries, and escalations. Monitor outputs and results to inform process efficiencies to achieve targets/ Accountable for adhering to and managing error rates according to the QA policy within the division. Develop and maintain adequate knowledge of data handling and ensure proper record keeping of related records/ Be open to Multiskilling in other areas within clinical risk Contribute to the targeted research into local and international clinical guidelines and funding policies/ Research medical literature and use evidence-based principles to generate enhancements in funding protocols. ? Prepares, participates in interdisciplinary discussions and presents cases at clinical meetings. Prepares reports and case summaries as needed. Participate in clinical projects/special assignments which are instrumental to the department Assist with special requests on any clinical decision-making when required. Provide support in conducting year-end testing, and special projects when required/ Provide knowledge and expertise of prevailing legislation within the funding environment. Application of Scheme Rules in all aspects, and updating of protocols/ Assist in identifying and adhering to fraud controls, risk prevention principles, sound governance and compliance processes, and tools to identify and manage risks. Support and provide evidence to all internal, external, and ISO audit requirements/ Maintain quality risk management standards in line with the requirements from ISO9001:2015. Maintain and enforce all clinical risk-related Service Level Agreements to minimize business risk and ensure business continuity/ Review and amend all related Standard Operating Procedures in consultation with the Supervisor: Clinical Risk to ensure business optimization. Adhere to all relevant laws, policies, and Standard Operating Procedures throughout the organization/ Treat information and documentation as private and confidential, and only disclose to any parties as according to the SOP’s and relevant regulations. Build and maintain effective internal and external stakeholder relationships for the purpose of expectations management, knowledge sharing, and integration/ Liaise with Medical Advisor, other Clinical Managers to optimize the care of the member managers. Contacting members and building positive relationships with the members to achieve positive outcomes/ Convene and attend meetings and present findings to relevant stakeholders when required. Liaise with members, brokers and healthcare professionals, and 3rd parties delivering exceptional customer service/ Provide educational information to relevant parties on health conditions, treatment, and patient care/ Provide input and support to the clinical committees, external advisory panel, and other committees as and when required. Knowledge of the current coding structures in the South African Health Care environment i/e/ ICD10’s, CPT4, NRPL, and PMB conditions, protocols and Scheme rules and medical aid industry
EXPERIENCE		QUALIFICATION
5 years of case management and disease management experience Minimum of 3 year’s experience in high-risk patient case management or care coordination program within a medical scheme or managed care environment/		National Diploma in Nursing (General, Community Health, Midwifery, and Psychiatry) Diploma in Intensive care an added advantage Registered Nurse (SANC)
KNOWLEDGE	SKILLS		ATTRIBUTES
Medical Knowledge Good working knowledge of ICD10 coding and other clinical coding Clinical Risk management Risk Management practices and principles Relevant legislation and regulatory frameworks Medical Aid Industry Claims Assessing Thorough medical Knowledge	Verbal and Written Communication Project Management Managed healthcare Business Acumen		Resilience Detail Orientation Innovative Thinking Customer Centric Results Focused Quality Focused Compliance Driven Analytical Thinking Problem Solving Judgement and Decision Making


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