Clinical Risk | Case Management Team Leader

About Kaelo

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.

The Clinical Team Lead is responsible for the operational leadership of the designated Case Management and Patient Management team at Kaelo. The role oversees the  emergency room and hospital admission  and care to Kaelo clients , ensuring delivery of high-quality, safe, and cost-effective services. Candidates will be required to support staff training and development, service improvement, and compliance with relevant standards and policies. They will be expected to provide regular feedback on operational activities to their line manager and ensure service level agreement standards are met.

This position reports to the Clinical manager.

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

Team Lead Specific Duties

• • Develop and maintain reports of daily activities, present analysis and feedback to the Clinical manager.
• Perform monthly Quality Assurance Audits for the team.
• Allocate daily roles and activities to team members based on demand and capacity.
• Where applicable, ensure that the team are appropriately allocated to afterhours duties, and maintain a record of timesheets to be submitted to the line manager for remuneration of afterhours activities.
• Ensure the team is meeting their specified SLA for all daily activities, where inefficiencies or issues are noted these must be raised to the line manager immediately.
• Supervise and report on the clinical auditing of claims conducted by the team
• Training and coaching the teams (including but not limited to: company policies and standards, product rules, clinical guidelines) to ensure high-quality clinical care management services are provided.
• Training for Netcare 911 teams
• Communicate with the Health Service Cantre Manager to ensure operational efficiencies between the Health Service Centre and Case Management team  
• Provide input and support for projects as required by the business

Daily operational activities

Case Management Team

• Ensure team is correctly and accurately allocated to cover all shift s.
• Assist team with Clinical decisions and escalations
• Draft and update Clinical SOP’s
• Guide team on funding decision based on product differences
• Review long term cases are correctly allocated and scheduled
• Review High-Cost cases received  weekly
• Review report sent daily, weekly and monthly.

HIV Patient Management team

• Check the maintenance of Service level
• Train team on latest guidelines to medication and protocol
• Update the SOP’s
• Review all Provider, system and patient escalations
• Keep  abreast with the latest guidelines

Administrative duties

• Line management of Case Management and Patient Management team• 1:1 monthly
• Leave management
•  Refresher team Training and development

• Quality auditing
• Rostering and scheduling

General

• Report any clinical escalations/concerns to the Clinical Review Committee or clinical risk management teams
• Maintain confidentiality in clinical conditions shared with her/him.

Key outcomes

• • Assist the Clinical and Medical Advisors to identify appropriate resources and guidelines  based on the latest trends to improve patient access to treatment and effective curative processes and care .  
• Ensure team maintain the correct standard of care with valid level of acuity and care at designated facilities.
• Ensure all team members maintain current nursing skills and knowledge base by attendance at workshops and seminars, completion of mandatory continued professional development, reading of professional journals, publications, and participation in professional organizations.
• Develop and maintain reports on the activities carried out within their team, presenting feedback and analysis of targets and outcomes.

EDUCATION: QUALIFICATIONS: ACCREDITATIONS WITH PROFESSIONAL BODY

REQUIRED

• Professional Nurse / Registered Nurse / Enrolled Nurse / ALS paramedic
• Degree / Diploma in Nursing
• A minimum of 5 years nursing experience.
• Experience across both the public and private health sector.
• Medical Aid or Insurance industry experience will be an advantage.
• Knowledge of ICD codes.

DESIRED

• Hospital ICU and theatre experience.
• PHC, Midwifery, and HIV experience is an advantage.
• Knowledge of PMB and DTP’s

TECHNICAL SKILLS OR KNOWLEDGE

REQUIRED

• Strong understanding of clinical codes.
• Attention to detail.
• Health risk assessment knowledge.
• Computer Literacy (Microsoft office). 

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PERSONAL ATTRIBUTES: BEHAVIORAL COMPETENCIES

• Accountability for clinical decisions made.
• Communication with all related health care workers, patient, and next of kin involved in a case.
• 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.
• Resilient and adaptive to different environments.
• Prioritizes patient care
• Self-development