Manager: Hospital 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 manage the provision of coordinated and appropriate medical care for the motor vehicle accident patients/claimants in hospitals.

Key Performance Areas

Policy  review and implementation.

• Provide input into the enhancement and implementation of the case management policies and strategy and plan to ensure an alignment with short term and long-term objectives
• Manage the implementation of the case management strategy approved, including as appropriate any special tasks or projects requested by management

 Clinical care management

• Manage the clinical status of claimants in accordance with the prescribed requirements throughout the case management process
• Manage the provision of clinical assessments to ensure that admissions adhere to approved criteria
• Ensure an accurate, appropriate, and complete diagnostic and procedural coding of all claimants’ records
• Manage the assessment of medical problems of the injured and the provision of quality of care
• Identify training needs of the Senior Officers: Hospital Case Management in line with the scope of work and the changes in the processes.

 Manage the provision of patient care

• Substantiate claimant hospitalization in terms of treatment, length of stay and level of care
• Ensure that a comprehensive assessment for claimants is performed and that a follow-up in accordance with the schedule determined/ agreed is undertaken.
• Ensure the monitoring of claimant treatment recovery progress to recommend adjustments where necessary
• Ensure that the claimants focused plan of care is coordinated and communicated to ensure attention is being focused on progression towards discharge.
• Ensure that the quality of health care provided to claimant is monitored to ensure they are up to acceptable standards.
• Manage and ensure that the discharge plan for the claimant is effective and allows for continued treatment after hospital discharge
• Ensure that claimants have the necessary utilities and amenities required for complete recovery
• Provide alternative treatment options to ensure a cost effective and efficient plan of care
• Manage and fast track case management reports and recommendations relating to the issuing of Undertaking Certificate and Interim Undertaking Certificates.
• Analyze and approve the recommendations for the transfer of claimants to better facilities of care

Case management and administration

• Manage all assigned cases
• Manage the development of practice and/or clinical guidelines for cost effective care
• Intervene on clinical discussion relating to the care of MVA claimants as per the SLA and MOU
• Present cases at case rounds/ conferences to obtain multidisciplinary perspective and recommendations to achieve optimal outcomes
• Manage the provision of claimants 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
• Identify financial and business risks to the Fund and escalate accordingly
• Analyze claimants care reports and make recommendation in preparation of the rehabilitation handover post discharge
• Manage high cost hospital cases and establish a forum for case managers to present high cost cases

 Manage the submission of invoices

• Validate and quality assure invoices submitted to ensure that they are aligned to the services and treatments claimed for
• Ensure financial and case management documentation supports accurate record-keeping and future requirements
• Put measures in place to safeguard 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  healthcare professionals for service rendered

Reporting

• Prepare and submit monthly and quarterly performance reports or as and when required to provide progress updates and/or inform management decisions
•  Develop functional reporting systems for case management, projects or performance reporting
•  Prepare proposals, briefings, presentations, reports, and  other documentation and provide management information both verbally and in report format.

Stakeholder management

• Engage in hospital visits where needed to build stakeholder relationships, proactively resolve queries and increase visibility to claimants
• Build productive relationship with healthcare professionals to ensure adequate referral rates to achieve budgeted occupancy level
• Build professional, long-term relationships with Funders and other stakeholders
• Ensure accurate service knowledge and advice and keep stakeholders informed of products and service options
• Manage the resolution of stakeholder queries and complaints promptly.

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
• ICU/Theatre or High cost Case Management experience will be an advantage.

Competencies required.

    Behavioral

•  Resilience
• Communication
• Working with people
• Network and Alliances
• Planning, Organizing 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
• Application of clinical intervention principles
• Knowledge  and application of dispensing of medicine, surgical material and procedures.
• Knowledge of healthcare operations
• ICD and CPT coding
• Medical case management
• Knowledge of Motor Vehicle Accident legislation
• Knowledge of Public Finance Management Act

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.