Senior Hospital case management

Introduction

Main Areas of Focus

In this Senior Case Manager role, the selected candidate will be responsible for providing on-site and remote support during periods of peak demand, staff shortages, or operational challenges, ensuring the continuity and stability of patient services. Their role will involve implementing specific business strategies and providing operational support across all Group hospitals, with a particular focus on stabilizing case management operations, increasing capacity, and driving continuous performance improvement in high-demand or low-performance environments. This role guarantees the consistent delivery of efficient and standardized case management processes, supported by robust quality control, adherence to policies and procedures, current regulations, and sound financial management. Furthermore, an operational case management component is maintained to ensure service continuity, maintain crucial clinical and financial information, and enable the proactive identification and resolution of systemic inefficiencies.

Functions and Responsibilities

Key Performance Areas: (include, but are not limited to)

Case Management Processes

• Provide hands-on operational support for case management within assigned facilities.
• Assess operational deficiencies, risks, and priority interventions at the time of implementation.
• Stabilize and optimize case management processes in accordance with Standard Operating Procedures (SOPs) and funder requirements.
• Coordinate multidisciplinary care, including medical rounds and collaboration with clinical and administrative teams.
• Manage high-risk and high-cost cases to ensure appropriate resource utilization.
• Ensure timely clinical updates and adherence to response deadlines.
• Oversee authorization processes and manage escalations in accordance with funder requirements.
• Monitor PAAS scores and levels of care to ensure clinical appropriateness.

• Analyze trends, rejections, and inefficiencies, and implement corrective actions.

• Prepare detailed implementation reports with key findings and improvements.

Clinical Coding

• Ensure accurate coding (ICD-10 and CPT/CCSA) in accordance with national and payer requirements.
• Review clinical documentation and collaborate with healthcare staff to ensure coding accuracy.
• Conduct coding audits and resolve discrepancies.
• Support the revenue cycle management process by reducing claims rejections and financial losses.
• Manage coding-related inquiries and maintain compliance with current regulations.

Financial and DNYB Management

• Manage financial risk throughout the patient journey, including pre-admissions and confirmations.
• Monitor authorizations and proactively address funding-related risks.
• Review operating room lists to ensure financial viability prior to admission.
• Manage DNYB cases (patients not requiring an inpatient bed) to meet the ≤5 day target. • Analyze profit and loss (P/L) and revenue management (ARM) accounts to optimize revenue and mitigate risks.

Stakeholder Management: Establishing and Maintaining Stakeholder Relationships

• Establish and maintain strategic relationships with internal and external stakeholders across multiple hospital sites, fostering collaboration and alignment with organizational and patient care objectives.
• Facilitate effective communication and coordination among admissions, case management, nursing, finance, and clinical teams to ensure comprehensive and continuous patient care.
• Ensure the effective management and resolution of inquiries and complaints, applying sound judgment and principles of service excellence to achieve timely, patient-centered results.
• Collaborate with attending physicians regarding financial risks and funding constraints to facilitate informed decision-making.
• Liaise with funding entities to resolve inquiries and complex issues related to authorizations, case management, and coding.

Desired Experience and Qualifications

Job Requirements: (include, but are not limited to)

• Bachelor of Science in Nursing or equivalent (Level 6 of the National Qualifications Framework).
• Relevant certification in clinical coding (advantageous).
• Current registration with the South African Council of Nurses (SANC) or a professional body.
• Proven experience in case management and clinical coding in a hospital setting.
• Strong understanding of health insurance regulations and hospital billing processes.
• Experience in financial risk management and DNYB (Disability, New, and Benefits).
• Proficiency in Microsoft Office; knowledge of SAP/Kronos is an asset.
• 5 years of senior-level case management experience in a multidisciplinary hospital.
• Strong understanding of health insurance regulations and funding protocols.
• Case management and admissions cycle processes. • Clinical coding (ICD-10, CPT/CCSA).
• Advanced ICD-10 qualification.
• This position requires frequent travel. Candidates must be willing and able to travel regularly.

Interested?

If you have at least 5 years of experience in case management in a senior role at a multidisciplinary hospital, please attach your CV, proof of SANC accreditation, copies of all your degrees and coding certificates, ID, and any other supporting documentation.