case manager – medical aid Job Description Template
Our company is looking for a case manager – medical aid to join our team.
Responsibilities:
- Willing to work standby hours for emergencies;
- Recommendation to the medical advisor on clinical interpretations in contexts with Scheme rules;
- Ongoing internal claims auditing and investigations;
- Accurate case management from pre-admission to discharge;
- Hospital pre-evaluation and pre-authorization;
- Arrange air and road evacuation from Mozambique to South-Africa;
- Establish and maintain relationships with existing service providers;
- Perform other duties and responsibilities, as assigned by Senior Management;
- Put action plans to minimise financial risks to the scheme;
- Maintain client relations with service providers;
- Daily, weekly and monthly reporting to management;
- Claims validation;
- Drive quality service in the Risk department;
- Monthly visits to service providers;
- Ensuring compliance with the medical aid scheme rules.
Requirements:
- Must perform independently Valid drivers licence;
- Knowledge of case management, billing, debt collection, tariffs and tariff structures is essential;
- Good understanding of risk principals;
- Bachelor’s degree in Nursing;
- Ability to work under pressure and meet deadlines;
- Knowledge of different COID and Medical Aid rules and managed health care policies;
- Good Management and Supervisory skills;
- Understanding of the relevant and current private healthcare legislation;
- Computer Literate;
- Registration with the Nursing Council as a Registered Nurse;
- Planning and analytic skills;
- At least 3 years’ experience in a similar environment;
- Extensive knowledge of ICD 10 and CPT 4 coding.