Medical Aid Case Manager jobs

Job Advert Summary

We are seeking an experienced and highly motivated Clinical Oncology Case Manager to join our Managed Healthcare team. The successful candidate will be responsible for managing hospital authorisations, oncology and high-cost cases, utilisation management, PMB assessments, and clinical case management activities in accordance with scheme rules, clinical protocols, and regulatory requirements.

Minimum Requirements

Education:

• Grade 12
• Registered nursing qualification essential.
• Intensive Nursing Science desirable.

Experience

Oncology experience desirable
Minimum of 2 years' experience in the managed care environment
Coaching/management experience 2 years essential
Medical Scheme Administration Experience 4 years plus essential
People Management 1 year essential
Soft Skills and Call center

Knowledge and Skills (maximum of 10):

Sound knowledge of the Coding Systems: ICD10 & CPT4 Principles and
System knowledge (MIP, MSO)
Computer literacy (MS Office)
Sound knowledge of the Medical Aid Industry, Rules & Regulations, ISO and other related legislation
Knowledge of Medical Aid Industry and Trends

Mutual respect and trust in order to reach individual and departmental dependability requirements
Goal orientated and accurate
Willingness to share knowledge
Able to work under pressure with high level of attention to detail-
Must be a team player
Goal orientated
Committed to customer satisfaction

Duties and Responsibilities

Ensuring successful Pre-Authorisation, Case management, Oncology and Disease mangement within the Clinical Risk Department.
Ensure adherence to Scheme Rules on all Oncology authorisations ,clinical updates and Benefits.
Effective handling of Internal/External Clinical Queries Communicate with members and service providers in order to address all Clinical related matters
Assist with Health Risk Management Monitoring & Management of members. Analyse and interpret reports, clinical results, and patient history information to provide an action plan per patient.
Refer appeals/ Highcost drugs and Section 21 to the Medical Advisor in order to make a final decision
Keeping up-to-date with the latest clinical data supplied by the suppliers, and interpreting, presenting and discussing this data with team members;
Maintaining knowledge of new developments in legislation , anticipating potential negative and positive impacts on the business and adapting strategy accordingly;
Create alternative treatment plans in order to ensure the most cost-effective treatment of case
Actively negotiate discount on requests on behalf of the Scheme
Advise service providers and members on cost effective in accordance with the Scheme Rules
Refer/ update and create standard operating procedure and work instructions
Facilitate enquiries regarding oncology benefits and discount
Provide training to clinical consultants on the oncology treatment and benefits
Reviews requests for Oncology for approval and communicate to members/providers
Keep record of all Oncology notes and savings made
Create reports for oncology innovation and and data when requested by the scheme
Propose DSP agreement to the Schemes
Propose benefit design changes to Schemes