Pinky Dineo Zondi

· Allocation of Length of Stay as per clinically necessity

· Interpretation of medical reports.

· Review procedural and admission costs to ensure cost effective and necessary care.

· Balancing cost and effectiveness of treatment to reduce re-admissions

· Review hospitalized members with chronic conditions.

· Active engagement with treating Dr’s, specialists and hospital case managers to ensure collaborative care.

· Update hospital admissions cases, procedures and review in relation to clinical appropriateness.

· Update clinical coding in accordance with coding standards

· Manage the financial risks for the entire duration of any hospital stay

· Provide complete and accurate updates and discharge information.

· Ensure compliance with service level agreements with all involved stakeholders.

· Linking of auxiliary service providers on authorizations as per scheme’s protocol (physio, Occupational therapist, social worker, Dietician.

· Telephonic and written communication with members

· Engage providers pertaining to shortfalls and applicable co-payments.

· Handling of escalations and providing resolution.

· Verify and confirmation of coding on hospital admissions.

· Document compilation for medical advisory team as per scheme protocol.

· Close monitoring of chronic registered patients in hospital.

· Review progress reports for sub-acute admissions to monitor rand Limit as per option.

· Facilitate of sub-acute transfers including transfer of skills and discharge home to ensure smooth transitioning.

· Closing all billing checks on cases for facilities for claims purposes.

· Reviewing wound care documentation approve NPWT-Vac Therapy.

· Initiate Discharge Planning.

· Facilitate transfers from network to Non network Facilities.

Close monitoring of neo natal admissions.

• Ensure to maintain Service Levels Agreement calls and workflow baskets at all times (SLA) in line with scheme’s turnaround time.
• Provider high quality service to all providers,members at all times telephonically.
• Approve admissions, procedures in accordance to managed care protcols.
• Authenticate member’s information as per POPIA.
• Capture pre -authorization based on clinical information provided and as per Standard Operation Procedure.
• Apply co-payments/ penalties as per scheme protocols.
• Request supporting documents for certain procedures for clinical review.
• Escalate high cost cases to the medical advisor for review and approval.

• Approve specialized scans in accordance with benefit limit and scheme rules.
• Report to fund manager all request for scheme exclusions for funding decisions.
• Escalate DSM IV FORM to In -patient psych department.

• Handling of pre-authorisations queries.

• Administer emergency pain relief as per standing orders.
• Conduct a physical assessment.
• Patient triage-screening of patients on arrival.
• Handling of out of town patients.
• Counselling/ health education for patients and families.
• Initiate patients on non-drug treatment.
• Follow Up on existing patient’s progress on treatment.
• Standby for after hour emergency.
• Work closely with neurologist – neurosurgeons and maxilla facial and oral surgeons.
• Interpreting for specialists.
• Case discussion with the specialists for SADAC members.
• Prepared patients for surgical procedures.
• Provide Post -operative care.
• Assisted during long hour procedures – order meals for providers/arrange transport for patients.
• Accurate clinical note recording at all times.

REFERENCES:

Private Health Administrators

1.Mr Sinethemba Mavundla (Team Leader for HBM) (031) 267 5000

2.The Headache Clinic (JHB) Mrs Ivy Mokhasi (Clinical team Supervisor) (011)484 0933