case manager – medical aid

case manager – medical aid Job Description Template

Our company is looking for a case manager – medical aid to join our team.


  • Willing to work standby hours for emergencies;
  • Recommendation to the medical advisor on clinical interpretations in contexts with Scheme rules;
  • Ongoing internal claims auditing and investigations;
  • Accurate case management from pre-admission to discharge;
  • Hospital pre-evaluation and pre-authorization;
  • Arrange air and road evacuation from Mozambique to South-Africa;
  • Establish and maintain relationships with existing service providers;
  • Perform other duties and responsibilities, as assigned by Senior Management;
  • Put action plans to minimise financial risks to the scheme;
  • Maintain client relations with service providers;
  • Daily, weekly and monthly reporting to management;
  • Claims validation;
  • Drive quality service in the Risk department;
  • Monthly visits to service providers;
  • Ensuring compliance with the medical aid scheme rules.


  • Must perform independently Valid drivers licence;
  • Knowledge of case management, billing, debt collection, tariffs and tariff structures is essential;
  • Good understanding of risk principals;
  • Bachelor’s degree in Nursing;
  • Ability to work under pressure and meet deadlines;
  • Knowledge of different COID and Medical Aid rules and managed health care policies;
  • Good Management and Supervisory skills;
  • Understanding of the relevant and current private healthcare legislation;
  • Computer Literate;
  • Registration with the Nursing Council as a Registered Nurse;
  • Planning and analytic skills;
  • At least 3 years’ experience in a similar environment;
  • Extensive knowledge of ICD 10 and CPT 4 coding.