Medical Manager

LYNETTE DRAAI

Profile

Lynette is a seasoned professional with over 10 years’ experience in the healthcare industry and COIDA claims.

Personal Details

Full Name: Lynette Draai

Known as: Lynet

ID Number: 750**********

Nationality: South Africa

Qualifications

Institution Year Qualification Obtained

Varsity College 2009 HR Diploma

Addington Nursing College 1997 Enrolled Nursing Auxillary Additional Training

● Advanced CPT & ICD coding (Discovery Health)

● Telephone etiquette

● HIV Management course

● Claims assessing hospital and related accounts

● Call centre

Skill Set

● Excellent written

● Excellent verbal communication

● EMMS & Paradgm (In-house

programmes)

● Computer Skills (MS Office Suite)

Professional Memberships

Member if SANC

WORK EXPERIENCE

Company: Sizwe medical aid (3sixty health)

Position Held: Preauthoration Consultant /Case management Duration: 01 October 2018 till present.

Responsibility

● Pre authorisation of Hospitalisation according to protocols and Limits

● Liaising with Doctors, hospitals and members.

● Giving excellent Customer service by Solving Queries timeously Company: FEM

Position Held: Claims assessor

Duration: 01 August 2016 to May 2018

Responsibility

● To administer and process claims to comply with COIDA and FEM’S standard operating procedures.

● Check information on general screen to correlate with employers’ reports

● Check if wages are declared on page 2 of the employers’ report and request the wages if not declared

● Code the injury and complete all fields for e.g. personal information

● Assess documents and project estimates in line with the injury

● Send out correspondence for all outstanding documents

● Follow up each claim monthly, sending more requests to stakeholder and inform of the status of the claim

● Check claim and follow up on outstanding information.

● If the documents have not been received, send for second and third requests.

● Confirm activity with a detailed file note

● Ensure timeous TTD payments

● Continuously adjust estimates as per latest medical reports received

● Account payment - Check for supporting documents

● Check if the supporting documents correspond with the account. E.g. treatment date, Dr’s name, practice number including the vat number.

● Refer to respective tariff for correct billing code

● Check for service providers and employee banking details and request same if not submitted

● Process account for payment in line with COID tariffs

● Pension and PD awards - Request final medical report from treating doctor

● Estimate possible award (LSW/CV) - Refer claim to Supervisor for assessment of PD/Pension

● Upon receipt of assessed claim from the manager, pay PD accordingly or refer claim to Pensions Department

● Generate and scan PD letter on the claim

● Advise employee accordingly

● Finalisation - Ensure all information on the General screen is correct

● Ensure all information on all the screens is correctly captured

● Ensure all accounts are received and paid in line with contents of the reports at hand

● If any outstanding accounts/reports, request and wait for 10 working days before finalising

● Ensure that the 3 outgoing correspondence request have been sent and scanned on claim

● Ensure the employee is informed of all the developments

● Navigate the claims for PD and TTD payments and that the PD letter is scanned on to the claim

● Ensure that the maximum and minimum wages letter is also scanned where applicable

● Check for duplicate payment on payment screen

● Correctly finalise claim within 5 working days

Reason for leaving: Personal reasons

Company: Rand mutual Assurance

Position Held: Medical Re-opening consultant

Duration: 01 Jan 2015 to 31 July 2016

Responsibility

● Pre-authorisation of cases older than 2 years(including spectacles, hearing aids and minor orthosis for non-pensioners) within time frames and in accordance with RMA policies

● Feedback to Contact Centre, Medihelp and action requests within TAT

● Scrutinises chronic medication scripts for non-pension claims and authorise as per SOL procedure

● Check all claims for reopening and referral to Regional Medical Managers with relevant documentations

● Pre-authorisation of Hospital Admission >5 days

● Follow up outstanding medical reports and other relevant information from Medical Service Provide and enlighten regarding RMA reopening and authorisation processes

● Liaison with Records Department for documents required for claim adjudication purposes

● Liaison with Branch staff regarding documents required for liability status on the claim to expedite authorisation process

● Liaison with Case Managers re Hospital authorised cases and inclusion in Case Management where applicable

● Document and keep records of all activities with timeous and accurate reporting to Manager Reason for leaving: better job prospect

Company: Universal Healthcare

Position Held: Pre authorization consultant

Duration: 1 July 2011 to 31 Dec 2014

Responsibility

● Pre authorisation of Hospitalisation according to protocols and Limits

● Liaising with Doctors, hospitals and members.

● Giving excellent Customer service by Solving Queries timeously Reason for leaving: Better Prospects

Company: Medis Medical

Position Held: Medical representative

Duration: 01 December 2010 – to 30 June 2011

Responsibility

● Presenting and demonstrating to customers.

● Calling on specialists and General Practitioners.

● Territory management.

● Attending congresses and seminars.

● Negotiating sponsors and sales discounts for clients.

● Maintaining diary and appointments.

● Keeping kilometre log.

● Writing and submitting weekly reports.

Reason for leaving: Contract ended

Company: Liberty Health (Vmed)

Position Held: RAF Hospital Case manager and investigator/Team Leader Duration: 01 July 2009 to 30 November 2010

Responsibility

● Identify valid MVA admissions

● Administration and case management relating to MVA claims collation and submission

● Maintain service delivery within Service Level Agreements (SLA’s)

● Perform data quality assurance

● Perform clinical quality assurance on claims information document control

● Collation and completion of claims forms

● Co-ordination and submission of claims to Back Office and Attorneys

● Ensure accurate, successful submission of Road Accident Fund (RAF) claims to Attorneys

● Ensure that the quality standards set by the company are enforced, specifically in terms of data integrity

● Ensuring compliance to contractual service level agreements

● Identifying system enhancements suitable for the Business Unit’s requirements

● Reporting on progress, productivity, contractual obligations etc Reason for leaving: Department closed

Company: Umhlanga Hospital

Position Held: Case manager

Duration: 07 May 2008 to 30 June 2009

Responsibility

● Application of clinical knowledge in the risk management (financial and clinical) of patients in terms of Length of Stay, Level of Care and medical aid benefits available.

● Application of clinical knowledge in accurate ICD 10 and CPT 4 coding of patient files

● Authorisation of final billing of medical schemes’ patient files.

● Daily personal visits of in-patients

● Daily liaison and communication with Medical Schemes, Hospital Nursing staff and medical practitioners.

● Ensure professionalism at all times.

Reason for leaving: Better prospects

Company: Discovery Health

Position Held : Clinical Assessor – Hospital claims Duration: 01 September 2002 till 30 April 2008

Responsibility

● Reviewing & auditing of hospital claims.

● Ensuring protocols & correct benefit limits applied before final payments of accounts.

● Ensuring correct level of acuity and length of stay maintained in hospital.

● Cost effective management of hospital claims as per scheme rules and government gazette.

● Investigation of possible non-disclosures

Reason for leaving: Better prospects

Company: Discovery Health

Position Held : Case manager

Duration: 01 September 2002 – 30 April 2008 (date same as previous position) Responsibility

● Update cases that come through health bridge.

● Update ICD codes and CPT codes as well as LOS and ELOS

● Liaise with the hospital case managers and doctors re patients that have been hospitalized for a long period and suggest step-down or discharge planning off cause considering the condition of the pt.

● Requesting DSM 4 forms from the psychiatrists who want to increase LOS in psychiatric patients.

● Presenting difficult cases to our panel as per protocol.

● Informing members about GSE’S and how are they going to be covered by the medical aid

● Explaining to members about our PMB’S and how the account will be covered by the Medical aid.

● Check cases from the hospital if they really need a specialised ward according to the condition and treatment given to the patients.

● Telephone queries – members and hospitals

● Requesting necessary documentation from supplier of service

● Investigating in appropriate use of drugs

● Identify and follow up of disclosure

● Investigate events not loaded

● Liaise with appropriate department re balance billing by hospital to member

● Ensure professionalism and a high standard of service is maintained in all dealings with all clientele

● gateway Queries

Reason for leaving: Multi-skilling

Company: Medscheme Holdings

Position Held: Case manager

Duration: 01 July 1998 – 31 August 2002

Responsibility

● Pre authorisation of Hospitalisation according to protocols and Limits

● Liaising with Doctors, hospitals and members.

● Giving excellent Customer service by Solving Queries timeously Reason for leaving: Better prospects

Company: Medscheme holdings

Position Held: Dental Authorisation Clerk-Specialised Duration : 01July 1998 – 31 August 2002

Responsibilities:

● Dental authorisation clerk-specialised/ call centre

● Authorising specialised dental procedures according to limits.

● Liaising with docotors, hospital and members

● Updating in hospital length of stays according to protocols

● Receiving motivational letters from members and doctors

● Preparing cases for the medical advisors.

● Sending correspondence to members on outcome of cases Reason for leaving: Transferred internally

REFERENCES

Available on request.

Leadership roles : 2IC in preauthorisation Department //currently mentoring the learners (Learnership for year)

Contact this candidate