Billing Operations Cluster BOC Case Manager

Role Summary

The Case Manager utilises clinical knowledge and expertise to mitigate financial risk by providing justification of the hospitalisation, encompassing level of care and length of stay to fund administrators. They collaborate with clinical coders to ensure complete clinical coding of the hospital event. The incumbent is responsible for liaising between patients, treating clinicians, and managed care organisations to provide an accurate clinical motivation/indication of the patient’s stay in hospital. The Case Manager works collaboratively with non-clinical case managers for efficient administrative processes and is an integral part of a team managing and coordinating treatment/care with clinical outcomes based on quality care, disease management, and cost-effectiveness. They act as an advocate for patients and their families and work with the billings manager to achieve billing cluster KPIs.

Key Work Output and Accountabilities

• Clinical Risk Management
• Apply clinical knowledge with regards to risk management of patient’s event in terms of LOS, LOC, and medical aid benefits.
• Apply clinical knowledge with regards to rejection management (financial and clinical) of patients in terms of LOS, LOC, and coding.
• Provide electronic clinical data to substantiate length of stay and level of care for patient’s stay in hospital.
• Ensure correct clinical coding for all patients as per clinical coding SOP.
• Apply clinical knowledge to ensuring that materials and services are correctly classified on the system.
• Escalate case management trends to the BOC Billings Manager for discussion in funder operational meetings.
• Monitor the patients in progress report and ensure that patients' ward movements, bed status, and level of care on the system are accurate.
• Facilitate discharge planning and movement of patients to step-down or rehab facilities.
• Efficient management of e-queries as allocated on Debtpack.
• Assist with any other duties assigned by the BOC and Billings Manager from time to time.
• Diagnostic and procedural coding
• Ensure appropriate, complete, and relevant diagnostic and procedural coding of all patient records within the cluster while the patient is in progress.
• Make use of Health Code Index.
• Build and maintain stakeholder relationships
• Liaise with a network of internal and external stakeholders to ensure final billing.
• 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.
• Legal compliance
• Compliance with all industry relevant legislative acts, regulations, and circulars.
• Compliance with Group Policies, Procedures, and Processes.
• Training and development
• Identify own training needs and communicate with line manager.
• Identify and ensure informal training for all relevant staff related to managed healthcare subject matter.
• Formal coding training via Insight platform is compulsory.
• Onboarding case manager Insight training to be completed.
• Teamwork
• 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.

Skills Profile

Education

• Required: B Degree/Diploma Nursing qualification or equivalent NQF level 6.
• Required: Enrolled nursing qualification or equivalent NQF level 4.
• Preferred: Qualification in associated Healthcare Sciences or Managed Care/ Case Management.

Work Experience

• Required: 3 years professional healthcare experience.
• Required: General administrative skills.
• Required: Computer literate.

Knowledge

• Required: Clinical background.
• Required: Understanding of a patient's journey in the private healthcare environment from patient admission to final billing.

Physical Requirements

In the event of any physical or psychological limitation that may impair the employee’s ability to perform the required job function, the employee must consult the employer for reasonable accommodation.

Values and Behaviours

• Netcare Values
• Care - The basis of our business. The professional, ethical patient care and services we offer at every level of the organisation.
• Truth - The crucial element in building relationships that work. Open communication with honesty and integrity is essential.
• Dignity - An acknowledgement of the uniqueness of individuals. A commitment to care with the qualities of respect and understanding.
• Compassion - The creative, compassionate, and innovative drive to do things better than before. To develop and implement successful healthcare solutions for all.
• Participation - The willingness and desire to work in productive and creative partnerships with others and the commitment to communicate.
• The Netcare Way
• I always greet everyone to show my respect.
• I always wear my name badge to show my identity.
• I always treat others with consideration and humility to uphold dignity
• I always act in the best interest of Netcare and others to show I care.
• I always listen with empathy and respond with kind action to show my compassion
• I always say thank you to show my appreciation.
• I always embrace diversity to strengthen inclusivity and belonging.

Skills

• Customer Focus and Service Delivery
• Personal Work Ethic
• Building Relationships
• Communication
• Teamwork
• Technical Knowledge

Working Conditions

• Professional flexibility in working hours while supporting daily business operations which may include weekends and night shifts where applicable.
• Will interact with internal and external customers through several different means.

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