7 Healthcare Facilities jobs in South Africa

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

ESSENTIAL REQUIREMENTS:

• 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

Please send your cv and supporting to (Email Address Removed).
If you have not received any feedback within 2 weeks' please assume that your application was not successful

Desired Skills:

• 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
  
  

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

Operational oversight of clinical risk, quality, and staff performance within the Hospital Risk Management department which includes pre-authorisation case management and clinical auditing.
Strategic leadership to drive continuous improvement, cost efficiency, innovation, and alignment to the Scheme's overall managed care strategy.

Key Performance Areas (KPAs)

• Responsible for the design, development, implementation and monitoring of all hospital-based risk management to improve access to and ensure high-quality, cost-effective management of entire hospital incidents.

• Promote a culture of accountability and professionalism, while developing systems, policies, and initiatives that proactively reduce clinical

KEY RESPONSIBILITIES

Clinical and Risk Management

• Lead continuous clinical, medical, and surgical risk evaluations, and report to the Scheme and company.
• Participate in the Clinical Review Team to support scheme and medical advisor decision-making.
• Stay current with clinical knowledge and new treatment modalities.
• Develop and implement clinical protocols, guidelines, and processes that drive quality and performance.
• Liaise with healthcare providers, scheme networks, and external stakeholders to manage member care pathways and mitigate clinical risks.
• Occasionally accompany case managers for onsite reviews of complex, high-risk cases.
• Analyse claims data and audit results to recommend targeted interventions that reduce fraud, waste, and abuse.
• Respond to Council for Medical Schemes (CMS) member complaints related to the department

Product & Scheme Development

• Assist with the conceptualisation, planning, and implementation of new managed care products.
• Contribute to medical scheme product development and benefit design.
• Stay abreast of industry developments, healthcare legislation, and regulatory requirements.
• Participate in tariff negotiations with hospital groups.
• Liaise with the Principal Officer and Medical Advisor for clinical alignment and strategic decision making

Operational Management

• Oversee day-to-day departmental operations and address operational inefficiencies.
• Ensure alignment of departmental performance with scheme sustainability goals and budget targets.
• Monitor and evaluate internal and external communication flows.
• Manage internal processes for confidential staff admissions, including pre-authorisation and appropriate claims payment.
• Coordinate weekly, monthly, and quarterly reports to business, schemes, and external hospital groups.
• Ensure adherence to SLAs and other compliance metrics.

Process Improvement & Systems

• Oversee the management and review of clinical SOPs, training manuals, and workflow documentation.
• Lead the implementation of new systems and process enhancements (e.g., IMed, Curus, Workflow, Billing Rules).
• Collaborate with Business Liaison and IT on system improvements; responsible for user testing and sign-off.
• Project manage new initiatives and enhancements from planning through to execution, including training and change management.

Leadership & People Management

• Provide coaching, mentoring, performance management, and quality control for team members.
• Drive a culture of accountability, professionalism, and service excellence.
• Manage staff KPAs, conduct quality control feedback sessions, and support disciplinary processes where necessary.
• Identify and develop talent through succession planning and continuous professional development.

QUALIFICATIONS AND EXPERIENCE

• Registered Nurse or Pharmacist
• A Minimum of 5-7 years experience in managed healthcare, hospital management clinical governance or medical scheme operations
• 3 years in a management or leadership role with experience managing clinical teams and driving strategic initiatives
• Legislation relating to the work of medical schemes
• A valid drivers licence is essential

Desired Skills:

• Registered Nurse or Pharmacist
• extensive experience within managed healthcare
• strong management skills
• extensive knowledge of hospital risk management within the medical schemes industry

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.

Duties And 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
  
  

• Registered Nurse
• Must be registered with 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 e.
• ICD10's, CPT4, NRPL, PMB conditions and clinical protocols
• Extensive clinical knowledge related to all aspects of patient
• 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
• Ability to accurately update and maintain cases
• 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 an advantageous
• Flexibility to tracel and a valid drivers licence is essentail
• Hospital case management experience will be advantageous
• Nursing experience within an ICU would be preferable
  
  

• Registered Nurse
• Hospital Case Management experience
• ICD and CPT coding is essential

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.

DUTIES AND 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

QUALIFICATIONS

• Registered Nurse
• Must be registered with 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 e.

• ICD10's, CPT4, NRPL, PMB conditions and clinical protocols

• Extensive clinical knowledge related to all aspects of patient

• 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
• Ability to accurately update and maintain cases
• 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 an advantageous
• Flexibility to tracel and a valid drivers licence is essentail
• Hospital case management experience will be advantageous
• Nursing experience within an ICU would be preferable

Desired Skills:

• Registered Nurse
• Hospital Case Management experience
• ICD and CPT coding is essential