Refilwe Mokoena
@refilwemokoena
Healthcare professional specializing in provider engagement, case management, and utilisation review.
South AfricaWhat I'm looking for
I am a registered healthcare professional with strong experience in provider engagement, case and claims management, and healthcare funding within medical schemes and managed care organisations. I build and maintain collaborative relationships with hospitals, clinicians, and multidisciplinary stakeholders to ensure clinically appropriate, cost-effective care.
My background includes high-cost case coordination, utilisation management, clinical reviews, and dispute resolution, with hands-on experience developing management reports and analysing provider-related data to support operational decisions and scheme sustainability.
I am committed to compliance with medical scheme rules, PMB legislation, and governance requirements, and I bring proven communication, reporting, and stakeholder-management skills suited to provider-facing roles in medical schemes or managed-care settings.
Experience
Work history, roles, and key accomplishments
General Case Manager
Life Healthcare
Nov 2025 - Present (2 months)
Act as key liaison between providers and funders, conducting clinical reviews and managing admissions to ensure compliance with medical scheme rules and funding protocols. Analysed provider data to support reporting, dispute resolution, and governance adherence.
High-Cost Case Manager
Afrocentric
Dec 2024 - Oct 2025 (10 months)
Coordinated and optimised high-cost care pathways by building provider relationships and developing utilisation and management reports to support scheme sustainability. Monitored claims and provider trends to inform cost-effective treatment plans.
Disease Risk Case Manager
3Sixty Health
Apr 2024 - Nov 2024 (7 months)
Liaised with providers on chronic disease management and PMB compliance, coordinating care plans, authorisations and follow-ups while maintaining accurate records and contributing to utilisation reporting.
Professional Nurse
Life Flora Hospital
Nov 2023 - Feb 2024 (3 months)
Served as shift leader and primary contact between clinical teams and hospital management, ensuring clinical governance, infection control and quality standards while escalating operational and clinical issues.
Community Service Nurse
Piet Retief Hospital
Jan 2022 - Dec 2022 (11 months)
Gained exposure to public-sector healthcare delivery and multidisciplinary collaboration while supporting provider systems and clinical service delivery during community service placement.
Education
Degrees, certifications, and relevant coursework
UAUniversity of South Africa
Bachelor of Commerce, Quantitative Management
2023 -
Enrolled part-time in a Bachelor of Commerce in Quantitative Management program beginning in 2023.
KwaZulu-Natal College of Nursing - Ngwelezana Campus
Diploma in Nursing, Nursing
Completed a Diploma in Nursing (General, Psychiatry, Community & Midwifery) under R425 curriculum in 2021.
Ngodini Secondary School
National Senior Certificate, General Secondary Education
Completed the National Senior Certificate (NSC) in 2014.
Availability
Location
South AfricaAuthorized to work in
Job categories
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