Billing Operations Cluster BOC Case Manager

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We are united by a common purpose of providing the best and safest care; and by our shared values of Care, Truth, Participation, Compassion and Dignity.

Netcare invites you to be part of our journey.

ROLE SUMMARY

The Case Manager utilising clinical knowledge and expertise, mitigates financial risk by providing justification of the hospitalisation, encompassing level of care and length of stay to fund administrators. Case managers work collaboratively with clinical coders to provide complete clinical coding of the hospital event. The incumbent will be responsible for liaising between the patients, treating clinicians and managed care organisations to provide an accurate clinical motivation/indication of the patient’s stay in hospital. The Case Manager will work collaboratively with the non‑clinical case managers for efficient administrative processes. The Case Manager is an integral part of a team, managing and co‑ordinating treatment/care, with the clinical outcomes based on quality care, disease management and cost effectiveness. (Appropriate treatment for the appropriate patient at the appropriate time). Being the advocate for the patients and where necessary, their families. The case manager works with the billings manager to achieve the billing cluster KPIs.

KEY WORK OUTPUT AND ACCOUNTABILITIES

DISRUPTIVE INNOVATION

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.
• Escalation of case management trends to the BOC Billings Manager for discussion in funder operational meetings.
• 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 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.

TRANSFORMATION OF OUR SOCIETY

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.
• 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.
• General administrative skills.
• Computer literate.

KNOWLEDGE

• Required: Clinical background.
• Understanding of a patients 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

At Netcare, our core value is care. We care about the dignity of our patients and all members of the Netcare family. We care about the participation of our people and our partners in everything we do. We care about truth in all our actions. We are compassionate about quality care and professional excellence.

• 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

Netcare is committed to providing quality care. Our basic service standard holds us accountable for the below seven behaviours which you will be accountable to uphold:

• 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 - The capacity to identify and respond to the needs of internal and external customers.
• Personal Work Ethic - Capacity to instil an ethic of quality and consistency in self and others.
• Building Relationships - Capacity to establish constructive and effective relationships.
• Communication - The capacity to clearly present information, either written or verbal.
• Teamwork - Capacity to cooperate with others to work towards a common goal.
• Technical Knowledge - The capacity to perform a technical function to required standards.

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.