Gwendoline Fredericks
Johannesburg
Summary
Dynamic Hospital Benefit Specialist with extensive experience at Discovery Health, excelling in case management and clinical coding. Proven track record in optimizing patient care while demonstrating strong negotiation and analytical skills. Recognized for enhancing operational efficiency and maintaining high standards of service delivery in fast-paced environments.
Overview
32
32
years of professional experience
Work History
Hospital Benefit Specialist
Discovery Health
Johannesburg
11.2021 - Current
- Company Overview: Insurance and Financial Services
- The role will function in various settings, predominantly in the general ward, ICU and High Care environments.
- The role includes focus related to specific conditions and/or providers of service.
- The primary role of the HBS is the management of LOS/LOA for members of DH administered schemes.
- Admission management at the relevant hospital, through assessment of the appropriateness of the setting of care and length of stay for in-patients as per the schemes' clinical guidelines.
- Discuss cases with the admitting doctor, hospital staff and patient regarding how the scheme benefits are allocated based on clinical protocols, where extended LOS or requested level of acuity is deemed clinically inappropriate.
- Eligible for these programmes are both identified proactively using data analysis and based on a set of criteria which can be applied by the HBS e.g. Current clinical condition and functional score; premorbid function; comorbidities; support system at home.
- 2IC Function: Onsite Pool management – removal of duplicates, Workflow queries.
- Daily administrative function which includes onsite pool volumes updates, allocation of pended cases.
- Managing HBS queries and escalations through to resolution.
- Enforcing policy, protocol and benefits decisions.
- Meeting daily Operational Targets, TWT, etc.
- QMC Coaching and updating RCA document.
- Ad Hoc duties based on business requirements.
- Attend certain meetings on behalf of FFM.
- Trending and tracking of team performance.
- Shift lead on the after-hours line.
- Insurance and Financial Services
Specialist Case Manager
Netcare
02.2020 - 08.2021
- Ensure all details on the Hospital Billing System are updated and accurate.
- Supply all details regarding patients history to clinical partners.
- Monitor and control costs for Managed Care Organizations patients.
- Confirm length of stay for all Managed Care Organizations patients.
- Accompany Managed Care Organization case managers on ward rounds in hospital.
- Assist with final authorization of Managed Care Organizations patient files.
- Ensure correct coding for all Managed Care Organizations patients.
- Consult with the relevant service providers regarding the patient care treatment.
- Assist with the transfer of patients to Rehab Hospital or stepdown facilities.
- Liaise network of internal or external stakeholders to ensure that managed care of patients is maintained.
- Arrange in-service training for relevant staff to meet the needs of the theatre department.
- Actively involvement in own professional development to maintain a satisfactory level of skill & knowledge.
- Keep up to date with Netcare’s evolving policies & procedures.
- Work effectively & cooperatively with others to establish & maintain good relationships that are mutually beneficial.
Specialist: High Cost Case Manager/ Quality Coach/ Specialist Medical Case Manager
Medscheme Holdings
03.2013 - 01.2020
- Company Overview: Medical Aid Administration Solutions & Health Risk Management
- Specialist: High-Cost Case Manager: Medshield: Dec 2018 – 31 Jan 2020.
- Reports to Team leader, acts as the 2IC in the absence.
- Manage high-cost funds for the scheme in consultation with Medical Advisors.
- Work from the high-cost report and update high-cost cases from R100000.00 / more than 30 days according to the clinical information if warranted.
- Negotiate rand value if patient can be downgraded to a lower ward where the treatment does not warrant particular ward stay.
- Attend high-cost meetings with scheme members.
- Discuss long term patients’ treatment and possible/actual savings recorded.
- Use past medical knowledge and experiences as well current knowledge in updating cases in order to save rand value for the scheme.
- If admission is related to protocol, all information will be requested from the Doctors rooms / Hospital Case Manager.
- Refer cases that needs expert advice to the Medical Doctors for a funding decision as per (SOP) Standing operating procedures and Business protocols.
- Knowledge of CPT (Surgical Procedure codes); BHF (Board of Health Funders) and ICD10 (Diagnostic & Related Illnesses) coding.
- Knowledge of the medical industry.
- Knowledge and application of scheme rules.
- Discuss the treatment and discharged plan with the Doctors and Case Managers.
- Extract data from various sources e.g. emails, faxes.
- Authorize hospital admission both medical and surgical understanding of medical terminology.
- Ensure correct submission of CPT / BHF in accordance with ICD and the correct treating provides is added.
- Call members if any co-payments are liable.
- Call center duties where needed, handle escalated queries from providers, members, and scheme.
- Identify trends and knowledge gaps to be compiled for reporting purposes inclusive of suggested recommendations.
- Conduct workshops relating to SOP where gaps are found.
- Checked the daily workload, compiled, and sent daily stats to the area manager.
- Action escalation sent from scheme members, providers, also delegate to staff members.
- Medical Aid Administration Solutions & Health Risk Management
Clinical Coding Specialist/ Case Manager/ Pre-Authorization Consultant
Discovery Health
04.2007 - 02.2013
- Company Overview: Insurance and Financial Services
- Clinical Coding Specialist: Jan 2011 - Feb 2013.
- Reported to Manager.
- NAPPI coding, CPT; BHF and ICD coding.
- Coordinated tariff files.
- Classified new Nappi codes.
- Pulled the new Nappi codes from Medi credit public domain / extract data.
- Researched information, called the suppliers and email request more information in order to classify the products.
- Reviewed and accurately interpreted tariff application and rulings.
- Evaluated tariffs for clinical appropriateness.
- Made recommendations to committee on tariffs based on funding rules.
- Answered all coding queries from stakeholders.
- Contributed to targeted research on clinical tariff guidelines and funding policies.
- Maintained the tariff file change control and audited the process for all amendments.
- Ensured accurate records on existing, new, and updated codes.
- Assisted with adhoc requests on clinical committees, external advisory panel and other committees as well as required.
- Maintained a pricing structure file for all products and disciplines.
- Executed changes in the pricing structure when required.
- Had discussions if products are new on the market.
- Kept daily stats of all products received and coded.
- Audited and updated the benefit baskets.
- Ensured that tariff files are delivered in the right format or has the right price.
- Insurance and Financial Services
Research Nurse Co-ordinator
Wits Health Consortium
06.2006 - 03.2007
Registered Nurse/Phlebotomist
Lancet Laboratories
01.2001 - 05.2006
Registered Nurse
Kenridge Hospital
06.1997 - 12.2000
Medical Claims Assessor Supervisor
AMA Superior Health / Southern Health
04.1995 - 05.1997
Professional Nurse & Senior Professional Nurse (Surgical Ward & Pediatric Ward)
Coronation Hospital
01.1994 - 03.1995
Education
Intermediate ICD10 and CPT coding -
Africode
01.2023
Certificate: Risk Management -
Wits Business School
01.2022
Diploma: Information Technology Management -
Alison
01.2021
Diploma: Operational Management - Business Intelligence & Knowledge Management Systems
Alison
01.2020
Diploma: Project Management -
Oxbridge Academy
01.2014
Diploma in Business Management -
Oxbridge Academy
01.2013
Diploma General, Community, Psychiatry & Midwifery -
Coronations Nursing College
01.1993
Matric - Grade 12
Bethelsdorp Secondary School
01.1985
Skills
- Planning and project management skills
- Verbal and written communication skills
- Interpersonal skills
- Managerial, Coaching and mentoring skills
- Presentation skills
- Strong negotiation skills
- Team player
- Self-motivated and pro-active
- Responsible and reliable
- Analytical and able to priorities
- Good time management skills
- Organized
- Adapts interpersonal style to suit different people or situations
- Adapts to changing circumstances
- Assertive and confident
- Attention to detail
- Customer focused
- Demonstrates integrity
- Shows urgency and passion for servicing
Languages
- English
- Afrikaans
References
- Jackie van Meyeron, Discovery, Manager, 0823304005
- Edwina Mahne, Medscheme, Manager, 0828510634
- Veronica Jansen, Medscheme, Manager, 0844184822
Salary Expectation
In line with client’s offerings
Personal Information
- Ethnicity: Coloured
- Notice Period: 30 days
- Gender: Female
- Nationality: South Africa
- Driving License: Code EB & own car
Timeline
Hospital Benefit Specialist
Discovery Health
11.2021 - Current
Specialist Case Manager
Netcare
02.2020 - 08.2021
Specialist: High Cost Case Manager/ Quality Coach/ Specialist Medical Case Manager
Medscheme Holdings
03.2013 - 01.2020
Clinical Coding Specialist/ Case Manager/ Pre-Authorization Consultant
Discovery Health
04.2007 - 02.2013
Research Nurse Co-ordinator
Wits Health Consortium
06.2006 - 03.2007
Registered Nurse/Phlebotomist
Lancet Laboratories
01.2001 - 05.2006
Registered Nurse
Kenridge Hospital
06.1997 - 12.2000
Medical Claims Assessor Supervisor
AMA Superior Health / Southern Health
04.1995 - 05.1997
Professional Nurse & Senior Professional Nurse (Surgical Ward & Pediatric Ward)
Coronation Hospital
01.1994 - 03.1995
Intermediate ICD10 and CPT coding -
Africode
Certificate: Risk Management -
Wits Business School
Diploma: Information Technology Management -
Alison
Diploma: Operational Management - Business Intelligence & Knowledge Management Systems
Alison
Diploma: Project Management -
Oxbridge Academy
Diploma in Business Management -
Oxbridge Academy
Diploma General, Community, Psychiatry & Midwifery -
Coronations Nursing College
Matric - Grade 12
Bethelsdorp Secondary School
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