Case Manager

Address: Sea Breeze Apartments Block MA*, Mbezi, Kinondoni, Dar es Salaam.

Tel: +255-****-***** /+255-***-***-***

Email: ********@*****.***

PROFILE

Dedicated mature Case Management Officer with a history of successful claims management and loss minimization. Extensive knowledge of insurance contracts, coverages, claims management programs and all related medical terminology. Creative and independent problem solver who also coordinates well with management and other company employees. Five years nursing experience in Central Hospitals and Private hospitals with six years medical claims management experience.

I am versatile and self motivated, very successful with a wealth of nursing, counseling and case management skills acquired across a wide range of demanding roles as Nursing Sister, Claims Assessor, Case Management Officer and Systemic Counselor.

I am articulate, good listener, hard working with excellent use of therapeutic communication techniques. Experienced in fraudulent claiming patterns from both service providers and clients. I am flexible and very keen to learn and can work as an individual or in a group setting.

SKILLS

Proficiency in Microsoft Office Suite 97/ Microsoft word, PowerPoint and Excel

Good communication and interpersonal skills

Gifted with negotiation skills

Knowledge of disease codes

Crisis management

English proficiency

CAREER SUMMARY

SANITAS HOSPITAL Dar es Salaam- (Tanzania) - November 2016 to date

SYSTEMIC COUNSELOR – Counseling Unit

Duties

Providing systemic counseling to walk in clients, referred clients or email cases in confidential setting.

Encouraging clients to discuss emotions and experiences

Helping clients define goals, plan action and gain insight and keep all records strictly confidential.

Working with individuals and groups to improve mental health

Examining issues including substance abuse, aging, bullying, anger management, stress depression, relationships, bereavement and suicide

Pre and post-test HIV counseling

Developing therapeutic processes and follow up clients at home, school where necessary

Taking a holistic approach, implementing Systemic approach to mental health care

Deciding on which case to refer to the Clinical Psychologist or other systems e.g to doctors, police, dietician etc.

MEDSCHEME Zimbabwe/Sovereign Health - August 2011 to 31 March 2016

CASE MANAGEMENT OFFICER (Health Risk Department)

Duties and Responsibilities

Pre-notification and pre-authorization of major events. (Fraud Reduction)

I was responsible for authorizations of hospital admissions and extremely expensive procedures (Major surgery, Maternity, CT and MRI scans, Prosthesis, Foreign treatment, Dialysis, Home Nursing, Chemotherapy Long range ambulance calls /Air evacuations).

My goal was to manage Insured benefits through the process of;

Membership confirmation, checking on availability of global benefits.

Evaluation of the request against Medical Scheme rules

Evaluation of the request against clinical / funding guidelines and protocols

Evaluation of whether the healthcare provider has been recognized as able to perform a specific procedure, especially relating to complex high cost procedures

Application of standard operating procedures per requested code

Admissions into registered facilities/ healthcare providers

Minimizing lengthy hospital stays through counseling.

In and Out of Hospital Case Management/ (Coordinated care)

Having knowledge of all admitted cases, I monitored all these cases with more attention being given to ICU and HDU cases to prevent unnecessary prolonged hospital stay (claim reduction strategies). I became client - centric in coordination of healthcare services including planning for discharge (including stepdown facilities).

From the discharge plan I followed up some cases initiating preventive care to control unwarranted hospital re-admissions. For terminal cases, I helped patients and their families develop self-care abilities which I facilitated through counselling to help them go through grief and prepared them for a dignified death at home.

Disease Management and Wellness programs (Adherence Counseling)

Through claims analysis, I identified high risk conditions like Cancer, Renal Failure, HIV/AIDS and Cardiovascular Accident (CVA) and implemented coordinated care and adherence counseling. I initiated wellness programs to educate the members and their families on preventative healthcare issues and disease management. Some of the programs included maternity care program and chronic care network (CCN)

Provider Engagement/ Negotiation for Reduction of Fees

I identified new service providers and facilitated their registration with the Fund, visited the existing providers finding out if there are any issues they would want the Fund to address or improve and communicating their positive or negative comments to the Fund. This created a good relationship between the Fund and service providers and made it easier for me to negotiate with these service providers for lower rates on behalf of the patient. I became the conduit of communication between service providers and the patients.

OTHER RESPONSIBILITIES

Attending Risk Management Committee meetings (RiMaC) facilitated by Association of Healthcare Funders of Zimbabwe (AHFoZ).

Periodically assisted the Business Development Manager in business presentations to corporate members and service providers.

Induction and/or training new employees on the different products and Fund Rules.

Counseling walk in clients.

WORKSHOP ATTENDED/SHORT COURSES

Customer care workshop.

Demand management, Managed care and Risk Management (June 2014).

Online Business English language (2014)

Online Telephone etiquette (2014)

Online Customer Care (2014)

Customer Service Training for Healthcare staff (August 2015)

ACHIEVEMENTS

I was nominated twice as one of the top three 110% Afrocentric Health Achievers Awards-April 2014 and March 2015. I managed to revive the Health Risk department in a relatively short space of time through implementation of wellness tips, application forms for various programs like maternity care program and home nursing. The unit became the best unit in providing counseling services to Cancer patients, terminally ill, HIV, gender based violence, dealing with unwanted pregnancies and bereavement counseling.

CLAIMS ASSESSOR

Duties;

Adjudication and processing of all medical claims.

Determine the amount of coverage the member should receive according to the procedure done and the global limit

Stay in contact with medical facilities providing service to determine accuracy of claims being made.

Meet members and/or service providers to discuss results rejected claims.

WORK HISTORY

St Joseph Clinic/Primary School - Counselling Attachment.

Feb 2010-Aug 2010.

Taroan Manufacturing ( Pvt) Ltd- Admin Officer Jan 2004 to Dec 2008

PSMAS (Head Office)- Claims Assessor

Oct 2001-Dec2003

Parirenyatwa Hospital Ward A1 - General Nurse

Sept 1997 Sept 2001

Chitungwiza Central Hospital Junior Nurse

May 1996- Sept1997

QUALIFICATIONS

Diploma in General Nursing

Bachelor’s Degree in Counseling

Diploma in Systemic Counseling

Certificate in Computer Foundation

Certificate in Anti -Fraud and Risk Control

REFERENCES

Danai Sithole (HR) Sovereign Health

+263-***-***-*** / *********@*********.**.**

Caroline Dyirakumunda (Operations Manager)

+263-***-***-***/ *************@*********.**.**

Memory Gororo (Membership Supervisor)

+263-***-***-***/ **********@*********.**.**

Dr George Kashangaki (Medical Doctor- Sanitas Hospital) +

+255*********/ ***********@*****.***

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