Social Work Jobs in Gauteng – Case Manager

Website Watershed Consulting

Job Responsibilities:

  • All medicines-related issues for special cases and off formulary items.
  • Analyse clinical, utilisation, and other data of members and healthcare providers.
  • Overall responsibility for incoming calls from Hospitals Case Managers relating to authorisations for procedures in Hospitals, Casualty, Specialist, GP, or Dental provider rooms.
  • Hospital case management from issuing a guarantee of payment (GOP) to final discharge and any follow-up treatment where required.
  • Share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.
  • Identify trends in utilisation, fraud, and other factors.
  • Ensure that all calls and cases are fully recorded on the MIP system accordingly.
  • Ensure efficient Customer Service and compliance to agreed SLAs.
  • Provide input and/or develop other processes to manage utilisation more efficiently.
  • Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.
  • Follow up with GP providers who may be overutilizing the “in rooms” procedures.

Job Requirements:

  • At least 2-3 years of experience in a similar role.
  • MIP Application System experience and advantage.
  • 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.
  • Sound understanding of the South African Health Industry, benefits, options, etc.
  • ICD codes, modifiers, and RPL tariff knowledge and understanding.

Qualification & Experience:

  • Matric
  • Registered Nursing diploma
  • Valid membership of SANC
  • Claims and Forensic Risk management certification
  • Registration with the Association of Certified Fraud Examiners (ACFE SA)

Job Details:

Company: Watershed Consulting

Vacancy Type:  Full Time

Job Location: Sandton, Gauteng, SA

Application Deadline: N/A

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