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A well-established company is recruiting for a

HOSPITAL BENEFIT MANAGEMENT CASE MANAGER

PRETORIA

Purpose Of The Position

To actively manage the clinical appropriateness and risk (both financial and clinical) of all hospital events and associated healthcare services in accordance with the relevant scheme rules, clinical protocols and funding guidelines. To participate in the clinical review of exceptional cases and to engage with various stakeholders including treating providers, hospital case managers, medical advisors and colleagues.

Key Functions

• Perform Clinical coding in accordance with CPT and ICD requirements and as per client standards
• Maintaining patient's clinical status in accordance with funder approval requirements for the duration of hospitalisation; keeping patients informed and managing the entire hospital stay's financial risk
• Provide complete and accurate updates and discharge information
• Receive hospital updates and assess each case based on clinical information - allocation of appropriate Length of Stay if clinically necessary
• Update Level of Care based on clinical information
• Review the costs to ensure cost effective and necessary care; balance cost and effectiveness of treatment to reduce re-admission
• Investigate and prepare cases for communication to the medical advisors, scheme, providers and members
• Member management of hospitalised patients with Chronic conditions who are registered on the active disease management programmes.
• Facilitation of the chronic and active disease registration of hospitalised beneficiaries who are diagnosed with one or more CDL conditions
• Escalation and resolution of unresolved high-cost cases
• Identification and preparation of high cost / high risk incidents and reported weekly to Clinical Specialist
• Discharge planning
• Communication with and support to Medical Advisors
• Call and written contact with Members and Providers
• Follow up on active cases with service providers relating to funding levels and updates (daily)
• Interpretation of medical reports
• Clinical decision making
  
  

• 3 to 5 years' experience within a managed healthcare or medical scheme environment
• Thorough, well-grounded clinical knowledge of hospital admissions, Length of Stay and Level of Care
• Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10's, CPT4, NRPL, PMB conditions and clinical protocols
• Extensive clinical knowledge related to all aspects of patient management.
• Solid understanding of value-based care
• Demonstrated ability to manage a portfolio of hospital cases
• Outcome focused with the ability to manage competing demands
• Establishing and maintaining effective relationships with key stakeholders.
• Ability to accurately update and maintain cases information.
• Excellent telephonic and written communication skills (will be tested)
• Computer literate - MIP/ Medcaps Application System (knowledge/ experience will be advantageous) and MS Office Suite of Products
• Reporting - MS Excel basic knowledge required (will be tested)
• Proficiency in English - verbal and written
• Verbal proficiency in additional languages will be advantageous
• Compassionate and attentive listener - you will need to interact with the family/ loved ones of members with long-stay hospital events
• Demonstrated ability to effectively deal with emotionally charged and stressful situations
• Self-motivator and the ability to work effectively in an independent environment
• Strong organisational and task prioritisation skills
• Outstanding multitasking skills
• Ability to research and analyse information
• High degree of accuracy and attention to detail
• Maintaining confidentiality of information
• Knowledge of medical aid policies and procedures
• Decision making skills
• Following through on commitments
• Flexibility to travel and a valid driver's license
• Hospital case management experience will be advantageous
• Nursing experience in an ICU setting will be a big advantage
  
  

• case manager
• hospital benefit management

As the leading medical recruitment agency in South Africa, our client has an exciting opportunity for a Case Manager (Hospital Benefit Management) based in Pretoria, South Africa. The Case Manager (Hospital Benefit Management) is to To actively manage the clinical appropriateness and risk (both financial and clinical) of all hospital events and associated healthcare services in accordance with the relevant scheme rules, clinical protocols and funding guidelines. To participate in the clinical review of exceptional cases and to engage with various stakeholders including treating providers, hospital case managers, medical advisors and colleagues.

Responsibilities

• Perform Clinical coding in accordance with CPT and ICD requirements and as per client standards
• Maintaining patient’s clinical status in accordance with funder approval requirements for the duration of hospitalisation; keeping patients informed and managing the entire hospital stay’s financial risk
• Provide complete and accurate updates and discharge information
• Receive hospital updates and assess each case based on clinical information - allocation of appropriate Length of Stay if clinically necessary
• Update Level of Care based on clinical information
• Review the costs to ensure cost effective and necessary care; balance cost and effectiveness of treatment to reduce re-admission
• Investigate and prepare cases for communication to the medical advisors, scheme, providers and members
• Member management of hospitalised patients with Chronic conditions who are registered on the active disease management programmes.
• Facilitation of the chronic and active disease registration of hospitalised beneficiaries who are diagnosed with one or more CDL conditions
• Escalation and resolution of unresolved high-cost cases
• Identification and preparation of high cost / high risk incidents and reported weekly to Clinical Specialist
• Discharge planning
• Communication with and support to Medical Advisors
• Call and written contact with Members and Providers
• Follow up on active cases with service providers relating to funding levels and updates (daily)
• Interpretation of medical reports
• Clinical decision making
  
  

• Qualified Registered Nurse with a valid SANC
• 3 to 5 years’ experience within a managed healthcare or medical scheme environment
• Thorough, well-grounded clinical knowledge of hospital admissions, Length of Stay and Level of Care
• Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols
• Extensive clinical knowledge related to all aspects of patient management.
• Solid understanding of value-based care
• Demonstrated ability to manage a portfolio of hospital cases
• Outcome focused with the ability to manage competing demands
• Establishing and maintaining effective relationships with key stakeholders.
• Ability to accurately update and maintain case information.
• Excellent telephonic and written communication skills (will be tested)
• Computer literate - MIP/ Medcaps Application System (knowledge/ experience will be advantageous) and MS Office Suite of Products
• Reporting - MS Excel basic knowledge required (will be tested)
• Proficiency in English - verbal and written
• Verbal proficiency in additional languages will be advantageous
• Compassionate and attentive listener - you will need to interact with the family/ loved ones of members with longstay hospital events
• Demonstrated ability to effectively deal with emotionally charged and stressful situations
• Self-motivator and the ability to work effectively in an independent environment
• Strong organisational and task prioritisation skills
• Outstanding multitasking skills
• Ability to research and analyse information
• High degree of accuracy and attention to detail
• Maintaining confidentiality of information
• Knowledge of medical aid policies and procedures
• Decision making skills
• Following through on commitments
• Flexibility to travel and a valid driver’s license
• Hospital case management experience will be advantageous
• Nursing experience in an ICU setting will be a big advantage
  
  

Career Opportunity: Case Manager Spinal Programme Management

Location: Pretoria (On-site)

Contract Type: Permanent
Salary: Market-related Cost to Company (including medical aid, provident fund, etc.) Based on experience

About our client:

Our client is a trusted and accredited managed healthcare organisation serving clients in the medical scheme industry. They are proud to support one of South Africas fastest-growing medical schemes and are expanding our specialist services to ensure members receive effective, value-driven healthcare. They are now seeking a skilled and compassionate Case Manager to join our dedicated Spinal Programme Management team.

Purpose of the Role

As a Case Manager, you will play a critical role in managing access, clinical appropriateness, and the financial and medical risk associated with spinal healthcare services. These include back and neck pain interventions, spinal surgeries, imaging, and conservative treatment pathways such as physiotherapy. Your role will require you to evaluate, guide, and coordinate care in line with scheme rules, clinical protocols, and funding guidelines.

Minimum Qualifications

• Registered Nurse with valid SANC registration
  OR
• Clinical Associate with a Bachelor of Clinical Medical Practice (BCMP) and valid HPCSA registration

Key Skills & Competencies

• Strong clinical knowledge of hospital admissions, Length of Stay (LOS), and Level of Care (LOC)
• Excellent understanding of the SA healthcare landscape, coding standards (ICD-10, CPT4), NRPL, PMB legislation, and treatment protocols
• Working knowledge of spinal, neuro-, and orthopaedic surgical environments (advantageous)
• Experience in managed care, case management, or related fields
• Familiarity with value-based care and holistic patient management
• Proficiency in MS Office (especially Excel) and experience with MIP systems (advantageous)
• Exceptional written and verbal communication skills (English required; proficiency in additional national languages is a plus)
• High emotional intelligence, attention to detail, and the ability to handle sensitive or complex cases with empathy
• Strong decision-making, prioritisation, and multi-tasking skills

Key Responsibilities

• Evaluate service requests, surgical quotations, and clinical codes related to spinal conditions
• Coordinate closely with the Medical Advisor and act on guidance received
• Engage with healthcare providers, members, and hospital case managers
• Manage hospitalised patients and facilitate discharge planning and follow-ups
• Perform case reviews and authorisation assessments
• Prepare documentation, clinical reports, and case studies as required
• Ensure accurate and timeous case record keeping and communication with stakeholders
• Continuously monitor and assess treatment efficacy, costs, and member outcomes
• Contribute to improving processes within the Spinal Programme and broader managed healthcare team

Additional Requirements

• Ability to work independently and manage a caseload under pressure
• Willingness to work overtime when needed to meet workflow targets
• High professional integrity and confidentiality in handling patient data
• Internal applicants must consult their Line Manager before applying

• Registered Nurse with valid registration with SANC

• Clinical Associate (Bachelor of Clinical Medical Practice (BCMP)) with valid registration with HPCSA

• Thorough, well-grounded clinical knowledge of hospital admissions, LOS and LOC.
• Excellent knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10s, CPT4, NRPL, PMB conditions and clinical protocols
• Extensive clinical knowledge related to all aspects of holistic patient management.
• Work experience within Orthopaedic and/ or Surgical theatre and wards will be advantageous.
• Solid understanding of value-based care.
• Demonstrated ability to manage a portfolio of active patient cases and to accurately update and maintain patient case information.
• Outcome focused with the ability to manage competing demands
• Establishing and maintaining effective relationships with key stakeholders.
• Excellent telephonic and written communication skills (will be tested)
• Computer literate - MS Office Suite (intermediate) required.
• MIP Application System experience will be advantageous.
• Reporting MS Excel (intermediate) required (will be tested)