Oncology Case Manager

Job Description, We are seeking an experienced and highly motivated Clinical Oncology Case Manager to join our Managed Healthcare team. The successful candidate will be responsible for managing hospital authorisations, oncology and high-cost cases, utilisation management, PMB assessments, and clinical case management activities in accordance with scheme rules, clinical protocols, and regulatory requirements.

, Requirements ,

Education

• Grade 12
• Registered nursing qualification essential.
• Intensive Nursing Science desirable.

Experience Oncology experience desirable

Minimum of 2 years' experience in the managed care environment

Coaching/management Experience 2 Years Essential Medical Scheme Administration Experience 4 years plus essential

People Management 1 year essential

Soft Skills and Call center

Knowledge And Skills (maximum Of 10) Sound knowledge of the Coding Systems: ICD10 & CPT4 Principles and

System knowledge (MIP, MSO)

Computer literacy (MS Office)

Sound knowledge of the Medical Aid Industry, Rules & Regulations, ISO and other related legislation

Knowledge of Medical Aid Industry and Trends

Mutual respect and trust in order to reach individual and departmental dependability requirements

Goal orientated and accurate

Willingness to share knowledge

Able to work under pressure with high level of attention to detail-

Must be a team player

Goal orientated

Committed to customer satisfaction

, Duties and Responsibilities ,

Ensuring successful Pre-Authorisation, Case management, Oncology and Disease mangement within the Clinical Risk Department.

Ensure adherence to Scheme Rules on all Oncology authorisations ,clinical updates and Benefits.

Effective handling of Internal/External Clinical Queries Communicate with members and service providers in order to address all Clinical related matters

Assist with Health Risk Management Monitoring & Management of members. Analyse and interpret reports, clinical results, and patient history information to provide an action plan per patient.

Refer appeals/ Highcost drugs and Section 21 to the Medical Advisor in order to make a final decision

Keeping up-to-date with the latest clinical data supplied by the suppliers, and interpreting, presenting and discussing this data with team members;

Maintaining knowledge of new developments in legislation , anticipating potential negative and positive impacts on the business and adapting strategy accordingly;

Create alternative treatment plans in order to ensure the most cost-effective treatment of case

Actively negotiate discount on requests on behalf of the Scheme

Advise service providers and members on cost effective in accordance with the Scheme Rules

Refer/ update and create standard operating procedure and work instructions

Facilitate enquiries regarding oncology benefits and discount

Provide training to clinical consultants on the oncology treatment and benefits

Reviews requests for Oncology for approval and communicate to members/providers

Keep record of all Oncology notes and savings made

Create reports for oncology innovation and and data when requested by the scheme

Propose DSP agreement to the Schemes

Propose benefit design changes to Schemes