Senior Case Manager – Hospital Group – Roodepoort Full Time NEW

About the Job:

Coordinate and optimise the end-to-end patient journey for an assigned caseload by aligning clinical, operational, and funding requirements to ensure safe, timely care, appropriate length of stay, accurate authorisations, and a smooth discharge, while improving patient experience and cost outcomes; for example, to coordinate between the patient and medical aids to secure payment for the hospital. Oversees complex cases, supervises junior staff, and develops strategic service plans to ensure high-quality care or resolution.

Requirements:

• Bachelor’s Degree in Nursing (NQF 6) or equivalent
• Current SANC registration, or relevant allied health registration
• Advanced computer literacy and high accuracy in clinical and billing systems
• 3–5+ year’s acute hospital experience
• 3+ years in case management, managed care, or patient flow
• Working knowledge of funder authorisations, ICD-10 coding, and tariff structures
• Working knowledge of nursing policies, procedures, and clinical governance
• Client-focused professionalism
• Clear and confident communication
• Stakeholder management
• Prioritisation and time management
• Detail focus and accuracy
• Problem-solving and timeous decision making
• Ownership and follow-through
• Adaptive to change and Resilience under pressure
• Integrity, confidentiality and discretion
• Collaboration and teamwork
• Continuous improvement mind-set
• Managed care authorisations and extensions
• Benefit interpretation (limits, exclusions, co-pays, PMB where relevant)
• Clinical motivation coordination and evidence packaging
• Revenue cycle awareness (authorisation → coding → claiming)
• Documentation standards and audit readiness
• ICD-10/coding literacy (documentation requirements)
• Hospital systems proficiency (HIS/billing/trackers)
• Patient flow + discharge planning coordination

Duties & Responsibilities:

• Manage complex client cases, including investigation, intervention, and resolution of escalated disputes. Receives high priority referrals from work streams to investigate and make partial decisions. Establishes treatment programs by setting schedules and routines; coordinating services being provided
• Supervise case management staff, conduct performance reviews, and assign workloads to ensure efficient service delivery
• Advocate for client needs, develop tailored service plans, and navigate complex systems for optimal outcomes. Contributes to the efficiency and effectiveness of service by offering suggestions and directing or participating as an active member of a work team. Identifies social, economic and physical needs and barriers with clients; assesses client’s support systems, available community resources and other factors to develop an appropriate Supports and advocates for need patient services by helping clients navigate
• Ensure all actions comply with legal policies, confidentiality agreements, and service level agreements (SLAs). Performs daily, monthly, quarterly, annual reporting and data entry
• Maintain thorough records, report on case progress, and conduct regular team meetings to review outcomes. Prepares complete and accurate case notes; writes correspondence, reports and other written materials; may prepare statistical reports and summaries. Determines client eligibility for internal and external program services; collects client information; evaluates and verifies applicable client information
• Provides job shadowing, mentoring, cross-functional training to new hires and other employees. Educates clients about, available resources, community programs and program specific outcomes
• Communicate with funders and external case managers for assigned cases to support consistent managed-care processes. Build strong internal partnerships across relevant hospital work streams to coordinate care and resolve issues. Uphold POPIA-aligned confidentiality and consent requirements, and advocate for patient rights through appropriate education and support
• Case-managed files show complete and accurate billing system fields (as per audit checklist)
• Authorisation-related updates captured within agreed SLA
• Month-on-month reduction in rejections attributable to admin/data errors (tracked by rejection reason codes)
• Applicable admissions have valid authorisation confirmed within required timeframe
• Extensions requested before authorisation expiry (no “lapsed auth” events)
• All authorisations/extensions have supporting documentation stored and traceable for audit
• Reduction in denials due to “no/invalid authorisation” or “late submission” reasons
• All high-risk benefit exhaustion cases show documented escalation, patient communication, and mitigation plan within SLA
• 90%+ of assigned cases initiated within 24 hours of admission
• 90%+ of managed cases have discharge plan documented within 48 hours
• Reduction in avoidable LOS days for managed cases (track “avoidable days” or LOS variance vs benchmark by DRG/pathway)
• Reduction in discharge delays attributable to admin/coordination (tracked with delay reason categories)
• Required motivations submitted within payer turnaround requirements (incl. extensions and high-cost items)
• Reduced “clinical information insufficient” denials/disputes for managed cases.
• Positive feedback from clinicians and nursing leadership on professionally useful case management contribution and responsiveness (via periodic feedback)
• 95%+ audit pass rate for managed-care documentation checklist
• Reduction in claim rejections/RTBs for managed cases vs baseline (especially “missing info” categories)
• 90%+ of payer queries responded to within agreed SLA, with complete documentation
• Reduction in internal rework requests from Billing/Coding for missing case management documentation
• 100% of high-cost/high-risk cases have a documented intervention plan + escalation path
• Reduction in non-recoverable costs attributable to funding failures (late auth, missing motivations, benefit exhaustion)
• Improved approval rates for high-cost items/extensions when clinically appropriate (track success %) due to timely engagement and motivations
• Achieves agreed satisfaction target from internal stakeholders (spot surveys/feedback) and reduced complaints/escalations
• Reduced repeat funder queries due to clear, complete, consistent submissions
• Demonstrated reduction in at least 1–3 recurring issues/denial reasons per quarter

Should you meet the above requirements, we urge you to apply by forwarding your CV along with any supporting documents to tracy@glass-house.co.za