Billings Operation Cluster Senior Case Manager

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The Senior Case Manager is responsible for the collaborative process of assessment, planning, facilitation, care condition, evaluation and advocacy for appropriate options and services. The Senior should liase with key stakeholders including the patient, the funder, the hospital and the multidisciplinary team to facilitate optimal patient outcomes. The incumbent is also responsible for promotion of quality and cost-effective outcomes. The Senior Case Manager will in addition assume responsibility for reports to be done, internal training, orientation, guidance and provision of overall support to case managers, confirmations, and clinical assessors.

•Application of clinical knowledge in the risk management of patients in terms of length of stay, level of care and medical aid benefits available.
• Ensure appropriate clinical information is transmitted to funders.
• Clinical coding as per work allocation.
• Facilitate onsite case management processes with the fund onsite case manager.
• Final authorisation of patient accounts prior to final billing as per work allocation.
• Active engagement, communication and Consultation with multidisciplinary team relating to managed health care of patient.
• Facilitate and co-ordinate authorisation process for transfer of patients to alternate care facilities or home
• Accurate and appropriate clinical motivation for patients length of stay and level of care in hospital.
• Management of billing and case management of accounts on alternate reimbursement contracts.
• Query resolution relating to managed health care of in progress patients.
• Query resolution relating to rejections and shortpayments on hospital accounts.
• Facilitate an efficient work flow process in confirmations and case management.
• Supervision of the case management and confirmation team.
• Training of new Case Managers and confirmations clerks.
• Ongoing training and feedback to case managers and confirmations.
• Ensuring that the length of stay and level of care is updated and escalated when necessary prior to final billing of an account.
• Team leader role in supervision, leadership and billing manager duties in the absence of a billing manager.
• Fulfilling the role of colleagues in their absence as per work allocation as and when required
Diagnostic and procedural coding.
• Ensure appropriate, complete and relevant diagnostic and procedural coding of all patient records within the hospital.
• Application of clinical knowledge for effective ICD 10 and CCSA coding of patient Events.
• Clinical coding of all patient events with valid ICD 10 and ccsa codes relevant to diagnosis, treatment rendered, and procedures carried out.
• Review clinical coding during patient stay in hospital.
• Application of clinical knowledge in the risk management of patients in terms of length of stay, level of care and medical aid benefits available.
• Monitor and action risk related to medical aid benefits and hospitilisation.
• Provide clinical data to substantiate length of stay and level of care.
• Accompany Managed Care Organisation Case Managers on ward rounds in the hospital, if required.
• Ensure correct clinical coding for all patients.
• Releasing of patient accounts for billing; relating to coding, LOS/LOC to ensure submission of an accurate hospital invoice. Consult with the relevant service providers regarding the patient treatment.
• Daily clinical rounds to all patients to allow for assessment and evaluation of patient to motivate for los, loc and treatment.
• Electronic clinical updates to managed care organisation/insurance providers, to motivate for patients’ level of care and length of stay in hospital.
• Final authorisation/releasing of all discharged patient accounts for final billing after reviewing authorisation of length of stay, level of care, and Coding. Monitoring and managing costs effectively for all patients/Risk management.
• Monitoring the patients in progress report and ensuring that patients ward movements, bed status and level of care on the system is accurate.
• Facilitate discharge planning and movement of patients to step-down or rehab facility.
• Assist with case management queries and investigations from funder, doctors and patients.
• Participate in the transition of care project as per policy.
• Reviewing and taking action on emails.
• Capturing of Risk factors
• Maintaining patient confidentiality
• Ability to implement changes effectively.
• Manage associated administrative tasks.
• Assist with any other duties assigned by the Billings Manager from time to time.
• Compliance with all industry relevant legislative acts, regulations and circulars
• Liaise with a network of internal and external stakeholders.
• Work effectively and co-operatively with others to establish and maintain good working relationships that are mutually beneficial.
• Develop collaborative relationships to help accomplish work goals.
Effective communication
• Effective communication to medical schemes by utilising the rules of engagement published in the Netcare Tariff and Billing Guidelines.
• Effective communication, collaboration and consultation with other role players in the healthcare team.
• Provide appropriate clinical information to MCO
• Effective and timeous communication with the member of the fund when appropriate.
• Identify own training needs and communicate with line manager.
• Identify and ensure informal training for all relevant staff related to managed healthcare subject matter.
• Actively participate as a member of a team to achieve goals.
Personal and professional development
• Active involvement in own professional development to maintain a satisfactory level of skill and knowledge.
• Keep up to date with Netcare’s evolving policies and procedures.

Join the team committed to providing the best and safest health and care.