Clinical Case Manager
Retail, Healthcare / Pharmacy
Minimum Requirements
- Senior Certificate / Grade 12 qualification plus Basic qualification accredited with the SANC in terms of Government Notice R425 (i.e.
- Diploma / Degree in General Nursing) or equivalent qualification that allows registration with the SANC as Professional Nurse and Midwifery (2026), a post-basic nursing qualification, with a duration of at least 1 year, accredited with the SANC in terms of Government Notice R212 specialty in ICU / Critical Care Science will be an added advantage.
- Minimum of four (4) years appropriate /recognizable experience in nursing after registration as a Professional Nurse with the SANC.
- NB: Non-OSD posts.
- Ability to function independently and to prioritize work.
- Leadership and sound interpersonal skills, problem-solving and decisionmaking skills.
- Good supervisory and teaching skills.
- Good knowledge of the Uniform Patient Fees Schedule (UPFS), Knowledge of the Medical Schemes Act 131 of 1998 i.e. the Chronic Disease List (CDL) and Diagnostic Treatment Pairs (DTP) and the application of Prescribed Minimum Benefit (PMB) legislation.
- in ICD-10 Code assignment and the ability to link patient diagnosis with procedure codes will be an advantage.
Responsibilities
- Identify and select externally funded patients for case management intervention Perform Case Management functions, i.e. obtaining preauthorisation for emergency admissions, verify benefits with medical schemes and send clinical updates and assist with the implementation of Case Management policies, protocols and procedures.
- Daily ward rounds to identify billable services done on RAF, M/A, SAPS, PCS, IOD, DOJ, H3.
- Liaise with the various role players e.g. clinicians and medical scheme case managers to monitor utilisation while in hospital.
- Monitor ICD-10 coding and other clinical information to prevent rejections by funders.
- Assist in Revenue office with ICD10 coding accuracy before submitting a claim, provide most appropriate procedure codes.
- Dissemination of information.
- Do clinical statistics monthly of the cases managed, ICD10 codes used, medical schemes, authorisations obtained, updates done and clinical rejections monitored.
