Minimum Requirements:

• Diploma/ Degree in General Nursing or Business-Related qualification.
• 3-5 years’ experience as RAF Case manager/Claims Adjudication Unit.
• Knowledge of ICD-10 and CPT coding.
• Knowledge of RAF Industry

Minimum work experience:

• To collaborate with the fund in ensuring that the patient/claimant have access to quality healthcare services from both Acute and Rehabilitation to achieve good clinical outcomes and reintegration back to the society.
• To establish a framework in enhancing service delivery to patients with due attention to the Fund`s financial obligation and payment processes.
• Conduct site case management through visits to different CHG facilities and Government facilities where CHG has signed MOA with and share clinical updates with the fund.
• Obtaining approval of care based on the Fund`s treatment protocols and an appropriate referral system for specialized management.
• Establish working groups with sufficient representation from the Fund and facilities to enable good clinical governance.
• Consult daily with all relevant health care providers with regards to patient treatment.
• Investigate and understand Funder, Doctors, Nurses and Patient needs to enable delivery of a quality service
• Ensure service knowledge and advice is technically accurate and provide stakeholders with relevant information to keep them informed of products and service options.
• Ensure conflict resolution and respond to any complaints or concern.
• Maximize revenue by applying clinical judgement to Length of Stay (LOS), Level of Care (LOC), formulary utilization, assistive devices / Prosthesis, diagnostic interventions, therapy intervention and procedural interventions and required change in the facility.
• Ensure complete, timeous and accurate reporting with appropriate levels of escalation to enable effective decision-making.