Unity Health is a well-established primary healthcare provider in the South African market. Our mission is to offer primary healthcare insurance solutions to the vast majority of South Africans unable to afford medical scheme coverage. We have a unique opening in our managed care division for a hospital case manager.
- Registered Nursing diploma
- Valid membership of SANC
Skills and Experience
- At least 2-3 years’ experience in a similar role
- MIP Application System experience and advantage.
- Sound understanding of the South African Health Industry, benefits and options etc.
- ICD codes, modifiers and RPL tariff knowledge and understanding
- Ability to liaise with external parties – clinicians and members
- Ability to work within an established team
- Excellent oral and written communication skills
- Customer centric attitude
- Excellent analytical skills and pays attention to detail
- Computer literate – MS Office suite, i.e. Word, Excel
- A good understanding of claims risk profiling
- Experience in claims auditing
Duties and Responsibilities
- Responsible for incoming calls from Hospitals Case Managers relating to authorisations for procedures in Hospitals, Casualty, GP or Dental providers rooms.
- Hospital case management from the issuing a guarantee of payment (GOP) to final discharge and any follow up treatment where required.
- Manages clinical risk by promoting sound principles and strategies to decrease claims over utilisation.
- Pre-authorisation of GP visits per benefit option rules.
- Classifies and prioritises risks based on the frequency of member visits to a provider.
- Ensure efficient Customer Service and compliance to agreed SLA’s
- Follow up with healthcare practitioners and members who may be over utilising visits and the “in rooms” procedures.
- Manage and maintain data integrity and update accordingly where necessary.
- Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
- Weekly review of all approved claims and ensure that all are settled according to correct tariffs and procedures.
- Ensure that all calls and cases are fully and clearly recorded on the MIP system accordingly.
- Supply all monthly management reports on cases and general case management processes and initiatives.
- Any other duties as assigned by your supervisor from time to time
Package & Remuneration
Salary: Market Related