Kaelo provides essential healthcare solutions ensuring the physical and psychosocial wellbeing of all South Africans towards lasting social change. Kaelo meets the Healthcare needs of Corporate and Retail clients across South Africa – products offerings include Medical Insurance, Medical Aid, Gap Insurance, Kaelo Money and employee assistance programmes.

Hospital Care Coordinators are responsible for end to end oversight of all in hospital cases for Kaelo clients. This includes management and coordination of care from the time that a patient is admitted throughout their hospital stay and discharge planning. A Hospital Care Coordinator is expected to provide appropriate authorisation updates on cases daily to ensure that optimal care is delivered to a patient at the most effective price point. They are expected to communicate with patients and providers on the benefit availability and limitations, review the correct level of care for admitted clients, and negotiate with health care providers.

This position reports to the Clinical Operations Manager and is supervised by the Clinical/Medical Advisor.

Note: This job specification provides a general outline of the responsibilities and qualifications expected of a Hospital Care Coordinator. Specific duties and requirements may vary depending on the organisation.

Clinical Auditor Responsibilities and Key Outcomes

Responsibilities include:

• Receive handover on cases admitted/authorised by the Acute Care Coordinators.
• Coordination of care for all hospital admitted patients.
• Ensure that correct benefit is utilised by member.
• Identify exclusions from the onset of request for treatment.
• Ensure that the correct level of care is allocated to the correct facility.
• Review appliances used in hospital against the current treatment guidelines.
• Provide information about treatment options, side effects, and possible complications of medications or procedures.
• Discussing diagnosis with doctors, specialists and other health care providers,
• Conducting assessments of patient needs, such as mental health issues or substance abuse problems and refer to EAP where applicable.
• Ensure service level agreements are met
• Use the latest available evidence based guidelines for patient management.
• Developing referral and treatment protocols for new or updated conditions identified.
• Report any clinical escalations/concerns to the Clinical Review Committee.
• Act as a patient advocate.
• Maintain confidentiality in clinical conditions shared with her/him.
• Assisting with monthly reporting: statistics, savings for example.

Key outcomes

1. 1. Utilize all resources and guidelines at his/her disposal to effectively assess, prioritize, advise, and manage admitted patients.
   2. Thoroughly complete documentation utilizing the appropriate computer software in compliance with the approved policies and procedures.
   3. Maintain current nursing skills and knowledge base by attendance at workshops and seminars, completion of mandatory continued professional devemopment, reading of professional journals, publications, and participation in professional organizations.

EDUCATION: QUALIFICATIONS: ACCREDITATIONS WITH PROFESSIONAL BODY

REQUIRED

• Registered Nurse
• Degree /Diploma in Nursing
• ICU/Theatre trained.
• Minimum 2 years Hospital Case Management experience.
• Medical Aid or Insurance industry experience and knowledge.
• Sound knowledge of ICD and CPT coding and DRGs

DESIRED EXPERIENCE:

• Proven experience in a managed healthcare setting with hospital case management.
• Strong understanding of healthcare regulations and accreditation standards.
• Excellent analytical, problem-solving, and critical thinking skills.
• Excellent clinical acumen and confidence in clinical decision making.
• Ability to communicate confidently with multidisciplinary healthcare professionals

TECHNICAL SKILLS OR KNOWLEDGE

REQUIRED

Strong understanding of clinical codes.

Attention to detail.

Health risk assessment knowledge

Computer Literacy 

PERSONAL ATTRIBUTES: BEHAVIORAL COMPETENCIES

• Accountability for clinical decisions made
• Communication with all related health care workers, patients and next of kin as needed.
• Writing skills for clear and concise notes that are easy to understand.
• Efficient and effective mindset to make clear clinical decisions without prejudice and interfering personal beliefs.
• Planning and organisation of work to be of great standards.
• Resilient and adaptive to different environments.
• Propensity for Self-development
• Ethical, always maintaining professional image and language.