Johannesburg, City of Johannesburg Metropolitan MunicipalityMember since 20 August 2023
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About
To work and succeed in a stimulating and challenging environment, building the success of the company while I experience advancement opportunities
Experience
Theatre/Recovery Sister 6 years
Case Management 3 years
Medical Advisor 2 years
Specialist : Clinical Processes 3 years
Specialist : Clinical Claims Consultant 4years
CASE MANAGER/PRE AUTHORISATION
End to End Authorisation Process ( including authorisation for hospital and alternative facilities)
ICD10 and CCSA Coding Reviews In relation to admissions, theatre related procedures and stock used(ward stock, pharmacy stock and theatre related stock)
(Medical and Surgical)
PMB and LOS Reviews ( pmb in accordance to orthopaedic cases and any other related surgeries)
High Cost Case Cost Containment and Reviews
Alternative to hospitalisations
Recommendations
Case reviews on a case by case
Basis
Discharge planning (holistically)
Nappi Codes in accordance to
Equipment utilisation as per
Coding Standards related PMB
Standard Operating Procedure adherence
Scheme Rules and Hospital
Contracting relating to escalations
System enhancement innovation
MEDICAL ADVISOR
Management of High Cost Case Managers
Clinical Reviews and Presentations
Council of Medical Scheme Reviews and Preparations
Prosthetic Negotiations (Cardiac and Orthopeadic)
Presentation of Complicated Cases at Clinical Review
Meetings
PMB Research in relation with all 7 provinces on Case
Findings
Coding Reviews
Standard Operating Procedure updates and amendments
Clinical Policies research on new findings
SPECIALIST: CLINICAL PR
Standard Operating Procedure Writer
Clinical Policy Writer
System Enhancement and Functionality Analyst
Implementation of New Scheme Rules
Chairing Workshops for enhancement training
Year End Projects really new devopments
Implement of new Hospital Contracts
Policy Reviews yearly
Coding Reviews All codes
PMB UPDATES
Business Risk Analysis Financially
Cost Containment development and Implementation
Project report all in one surgeries (ARM MODELS )
Negotiations with all Hospital Groups
SPECIALIST: CLINICAL CLAIMS CONSULTANT
Auditing of Hospital Claims
Payment Analysis as per Hospital Contracting and related Scheme Rules
Clinical Reviews read Short payments on Hospital
Claims
Stale Claims analysis, reviews and Clinical
Recommendations for payments
CCSA AND ICD10 correctness analysis re payments and
Hospital Admissions according to Billing, before
Processing and Reprocess of Claims
Medikredit Updates and adherence really protocol payments
Fraud, Waste and Abuse Reporting really Risk Analysis and Hospital Risk Alerts
PMB Reviews in accordance to Council of Medical
Schemes Act, Hospital Contracting and Related Scheme
Rules
Resolutions for Route Cause Analysis
Feedback on Error Finding really Claims and related
Correctness
Fraud Reporting
Education
R425 Nursing Diploma (General, Community, Midwifery and Psychiatry)
Reviews
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