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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE: 

Manage a case in accordance with the benefits of a selected medical scheme 
SAQA US ID UNIT STANDARD TITLE
242681  Manage a case in accordance with the benefits of a selected medical scheme 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 4  NQF Level 04  2 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Passed the End Date -
Status was "Reregistered" 		 2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This Unit Standard is intended for Case Managers and Disease Managers at medical schemes who liaise with providers or providers who liaise with medical schemes or other providers to ensure the appropriate level of care in accordance with the rules of a selected medical scheme option.

The qualifying learner is capable of:
  • Interpreting the rules of a medical scheme and relevant legislation to determine benefits.
  • Analysing Service Level agreements between a medical scheme, members and service providers.
  • Applying medical knowledge to monitor a case.
  • Liaising with different role players in order to manage the benefits of a scheme. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    It is assumed that learners are competent in Communication and Mathematical Literacy at Level 3. 

    UNIT STANDARD RANGE 
    The typical scope of this Unit Standard is:
  • Case management relates to appropriate cost effective treatment, case outcomes measurement and repeat admissions.
  • Appropriate care includes, but is not limited to, level of care, length of stay, facility, drugs and devices. 
    		•

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Interpret the rules of a medical scheme and relevant legislation to determine benefits. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Scheme rules are analysed and interpreted to determine cover and exclusions. 

    ASSESSMENT CRITERION 2 
    Knowledge of relevant legislation is applied to ensure compliance. 

    SPECIFIC OUTCOME 2 
    Analyse service level agreements between a medical scheme, members and service providers. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Accepted managed care protocols are explained with reference to the application in service level agreements. 

    ASSESSMENT CRITERION 2 
    Service level agreements are analysed to identify clinical protocols, formularies and any other measures relating to delivery of services. 

    ASSESSMENT CRITERION 3 
    Agreements between a medical scheme, providers and members are analysed to identify line of communication and contractual agreements. 

    SPECIFIC OUTCOME 3 
    Apply medical knowledge to monitor a case. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    A risk management process and medical knowledge are applied to a case to evaluate the effectiveness of the case management programme. 

    ASSESSMENT CRITERION 2 
    The case management process is explained with reference to a specific medical scheme and scheme rules. 

    ASSESSMENT CRITERION 3 
    A case is analysed and a decision is made on the most appropriate care to be funded by the scheme based on sound scientific evidence. 

    SPECIFIC OUTCOME 4 
    Liaise with different role players in order to manage the benefits of a scheme. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Role players in a case are identified and the roles and responsibilities of each are explained in a specific case. 

    ASSESSMENT CRITERION 2 
    The role of the case manager in a selected case is explained with reference communication, facilitation and facilitation. 

    ASSESSMENT CRITERION 3 
    Documentation required in a specific case is produced according to the requirements of a selected medical scheme. 

    ASSESSMENT CRITERION 4 
    Patient Rights and Scheme Rights are explained with reference to the Charter of Patient Rights, Rules of the Scheme and accepted ethical practice. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
  • Anyone assessing a candidate against this Unit Standard must be registered as an assessor with the relevant ETQA or ETQA where a Memorandum of Understanding (MOU) exists with the relevant ETQA.
  • Any institution offering learning that will enable achievement of this Unit Standard must be accredited as a provider through the relevant ETQA or ETQA where a Memorandum of Understanding (MOU) exists with the relevant ETQA.
  • Moderation of assessment will be overseen by the relevant ETQA according to the moderation guidelines and the agreed ETQA procedures. 
    		•

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Learners are capable of identifying and solving problems in which responses show that responsible decisions using critical and creative thinking have been made in applying medical knowledge to monitor a case. 

    UNIT STANDARD CCFO WORKING 
    Learners are capable of working as members of a team as case management requires liaison, negotiation and facilitation. 

    UNIT STANDARD CCFO ORGANISING 
    Learners are capable of organising themselves and their own activities in ensure the appropriate level of care based on scientific evidence and in accordance with the rules of a selected medical scheme option and producing the required documentation. 

    UNIT STANDARD CCFO COLLECTING 
    Learners are capable of collecting, organising and critically evaluating information in producing the documentation required for a case. 

    UNIT STANDARD CCFO COMMUNICATING 
    Learners are capable of communicating effectively in liaising with role players and facilitating, and negotiating to manage the benefits of a scheme. 

    UNIT STANDARD CCFO DEMONSTRATING 
    Learners are capable of seeing the world as a set of related systems in understanding the role of clinical protocols, formularies and any other measures relating to delivery of services and effective case management. 

    UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    Search words: risk management, case management, disease management. 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Elective  57613   Further Education and Training Certificate: Short-Term Risk Management  Level 4  NQF Level 04  Passed the End Date -
    Status was "Reregistered"     		 2012-06-30  INSETA 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    NONE 


    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.