Consultant: Medical Management

1 week ago


East London, South Africa Road Accident Fund Full time
Job title : Consultant: Medical Management Job Location : Eastern Cape, East London Deadline : December 13, 2024 Quick Recommended Links
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Key Performance Areas

Medical management

  • Conduct medical assessment and compile injury assessment reports.
  • Conduct assessments and bill reviews on submitted claims, focusing on the appropriate level of care, the length of stay, and quality of care.
  • Incorporate tariffs, cost savings initiative recording, and treatment protocol to ensure that all service providers adhere to the rules, and the tariff as guided by the RAF and / or any that is considered reasonable.
  • Preauthorise submitted claims aligned to RAF clinical guidelines including the RAF formulary, treatment protocols and related tariffs.
  • Escalation of complex cases for multi-disciplinary review and adjudication.
  • Participate in the consultations process on the implementation of medical claims processes.

Exception handling.

  • Ensure the implementation and maintenance of a formal exception handling process within the medical management.
  • Maintain the documentation and regular updating of the exception handling process.
  • Maintain the implementation an unusual occurrence procedures.

Reporting

  • Track and report against set objectives and targets.
  • Report on emerging risks.
  • Provide ad hoc reports on process improvement initiatives.
  • Produce documents, briefing papers, reports, and presentations.

Stakeholder management

  • Deal with/and respond to correspondence.
  • Maintain healthy relationships with all stakeholders.
  • Follow up and resolve all queries, up and make recommendations on which corrective actions are appropriate.
  • Follow up and feedback to all stakeholders to keep them updated on the status of a query.
  • Respond to queries within the predefined turnaround times.

Qualifications

  • Bachelor’s Degree/Advanced Diploma in Health Sciences /Medical related qualification.
  • Registration with HPCSA/SANCA

Experience

  • Relevant 3 years’ experience in a Medical related environment

Technical and behavioral competencies required

  • Claims management process/ processes and systems.
  • Medical product management
  • Medical bill reviewing
  • Medical case management
  • Complex problem identification, solving and decision making
  • Customer value proposition
  • Strong clinical analytical capabilities
  • Knowledge of motor vehicle accident legislation
  • Planning, Organising and Coordinating.
  • Personal Mastery.
  • Judgement and Decision Making.
  • Ethics and Values.
  • Client Service Orientation.

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