Manager: Field Case Management- Groote Schuur / Tygerberg Hospital

The Road Accident Fund’s mission is to provide appropriate cover to all road users within the borders of South Africa; to rehabilitate and compensate persons injured as a result of motor vehicle accidents in a timely and caring manner; and to actively promote safe use of our roads.

Purpose of the Job:   To provide effective case management services within the RAF by managing rehabilitation and health care needs for the injured.

Key Performance Areas

Policy and strategy review and implementation

•  Provide input into the enhancement  and implementation of the case management strategy and plan that ensure alignment with short term and long-term objectives
• Keep up to date with effective case management policy and practice execution strategies

 Case Management and administration

• Manage all assigned cases
• Manage the appointment of caregivers and the provision of the necessary training
• Ensure that case management programs objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained
• Presents cases at case rounds/conferences to obtain multidisciplinary perspective and recommendations to achieve optimal outcomes
• Manage the provision of claimants/caregiver care plan and compliance reporting
• Manage claimants’ case management plans, authorizations, assessment, and levels of care
• Manage the review of medical records to identify specific medical issues
• Manage the development of practice and/or clinical guidelines for cost effective rehabilitation of care
• Identify financial and business risks to the fund and escalate accordingly

 Management of claimant rehabilitation care

• Manage claimants’ progress and outcomes
• Manage and analyze the determination of the claimant needs and coordinate reasonable recommendations for all the necessary and identified modifications in line with the nature of the claimant’s medical condition
• Manage an in-home assessment by Senior Officer: Field Case Management to assess members overall health needs, which includes medication reconciliation
• Manage the identification of gaps in care as claimants transition from a care facility back to their home
• Provide management direction and guidance in ensuring that healthcare services are accounted for by liaising with relevant personnel for authorizations and ensuring compliance with case management procedures, standards and protocols
• Manage the approval and appointment of service providers in line with the defined scope of work
• Determine the suitable rehabilitation stay for the claimant based on the required level of care and monitor the implementation
• Ensure that ongoing support to the family is provided on coping mechanisms post discharge
• Manage and monitor the rehabilitation plans of the claimant/client for effectiveness.

Integration of back-to-back work and community

• Corporates with the treating physician to obtain a full or conditional release to return to work before injury becomes a lost time claim where it is necessary.
• Coordinates with the employer to develop a modified duty job for the injured worker who cannot immediately return to his/her full pre-injury employment where required
• Ensure successful integration of the claimant back to the family and educate the claimant and family on the condition of the claimant
• Identify community resources based on the claimants’ need.

 Manage the submission of invoices

• Validate and quality assure invoices submitted to ensure that they are aligned to the services and treatments claimed for
• Put measures in place to guard against the submission of fraudulent invoices
• Manage the compliance of invoiced services from service providers and ensure validity in line with RAF Act and guidelines
• Manage timeous payment of service providers

Reporting

• Manage the completion of all relevant reports (time sheets, expenses, program specific reports) as per specified timelines and required standards
• Provide report on all assigned cases, and the monthly rehabilitation reports of  the claimants
• Prepare and submit monthly and quarterly performance case management reports or as and when required to provide progress updates and/or inform management decisions
• Ensure complete, timely, and accurate reporting with appropriate levels of escalation
• Provide reports on the possibilities of back to work integration for claimants
• Reporting on the costs associated with the undertaking certificate against what has been spent on caregivers.

Stakeholder management

• Build productive relationship with healthcare professionals to ensure adequate referral rates to achieve budgeted occupancy level
• Ensure accurate service knowledge and advice and keep stakeholders informed of products and service options
• Resolve stakeholder queries and complains promptly
• Manage relations with service providers and health professionals to ensure adherence in line with the protocols and service level agreement

People Management

• Ensure the sourcing, development and retention of a high-performance team
• Manage the recruitment of the operational workforce in line with employment equity targets
• Manage staff in the department to ensure that they achieve their objectives in line with the strategic objectives of the RAF
• Manage the implementation of human capital processes and procedures to control/ regulate workplace conflict and/or institute corrective measures and consultation processes to address deviations from standards
• Allocate, direct, motivate and evaluate subordinates to help them achieve their individual goals.

Qualifications and Experience       

• Bachelor’s Degree / Advanced Diploma in a Health sciences or Medical related Degree.
• Postgraduate in Health Sciences or Medical related qualification will be an added advantage
• Registration with the relevant Health professional body
• Relevant  6-8 years’ experience in Nursing or Case Management environment of which 2 years must have been on a management/supervisory level/area of expertise

  Competencies required.

  Behavioural

•  Resilience
• Communication
• Working with people
• Network and Alliances
• Planning, Organising and Coordinating
• Employee engagement
• Personal mastery
• Judgement and decision making
• Ethics and values
• Client services orientation

    Managerial

• Change management
• Coaching and mentoring
• Conflict management
• Critical and innovative thinking
• Direction setting
• Facilitation and presentation skills
• People management
• Policy conceptualization and formulation
• Risk management
• Programme/project management
• Service delivery innovation
• Stakeholder development and relations
• Reporting

     Technical

• Knowledge of claims management end to end management process and systems
• Coding standards and protocols
• Core specialities in the case management process
• Knowledge of healthcare operations
• ICD and CPT coding
• Medical bill reviewing
• Medical case management
• Knowledge of Motor Vehicle Accident legislation
• Public Finance Management Act knowledge

Road Accident Fund Values

• Integrity
• Compassion
• Accountability
• Respect
• Excellence
• Empathy

NB: “RAF offers Total Employment Cost packages with no additional contributions from the Employer, successful candidates are required to structure their packages in a manner that will suit their needs”

The Road Accident Fund subscribes to the principles of employment equity and preference will be given to People with Disabilities.

Applicants who have not received any correspondence from us within six weeks from the closing date can consider themselves unsuccessful

Security Vetting shall be conducted on all prospective employees

It is the applicants’ responsibility to have foreign qualification evaluated by the South African Qualification Authority (SAQA) and to provide proof of such evaluation.