Case Manager - Benoni

Our preauth department is looking for a case manager who will be responsible for improving clinical outcomes,increase patient satisfaction and promote cost effectiveness.

Key Tasks

Manage Pre Auth cases:

• Assist to determine admission requirements.

• Assist to provide the pre-auth team with valid recommendations for pre-auth request

• Coordinate and provide care that is safe, timely, effective, efficient, equitable and client centred

• Manage declined cases

• Review case progress and determine case closure

• Assess treatment needs

• Monitor and evaluate treatment plans and progress

• Facilitate hospital admissions and LMS dispatch

• Help members make informed decisions about treatment options

• Promote quality and cost-effective interventions and outcomes

• Adhere to professional standards as outlined by protocol, rules and regulations.

• Maintain constant contact with treatment DR/Hospital

• Educate members and medical staff of limits of benefits

• Respond to quires and complaints within SLA (24 Hours)

• Maintain high standard of product knowledge

• Monitor and recommend training interventions within pre auth department

• Hospital case financial reconciliation accuracy

• Clinical intervention documentation completeness - clinical notes and doctor's orders

• Manage Error ratio in clinical reporting

• Manage High-cost case escalation accuracy

Perform administrative duties:

• Review medical records to identify medical issues

• Complete and present case review preparations

• Compile and submit periodic reports

Clinical Bill Auditing

· Assessing of ICU/HIC, continuation cases, high-cost claims and claims exceeding LOS of 5 days

• Assess claim based on pre-authorisation and case management agreements
• Check for over billing and/or over servicing and incorrect coding, or charges

· Adjudicate claims and resolve claim disputes with service providers and obtain applicable amended accounts.

• Submit amended accounts to Claims Department for payment

· Exclude possible non-disclosure of pre-existing conditions

· Maintain SLA to action and provide feedback to OTRS tickets within 48 hours

· Keep abreast of amendments to policy rules, benefit options, legislation, protocols, processes, and systems