Head: Medical Management

3 weeks ago

Johannesburg, South Africa Rand Mutual Assurance Full time

**THE JOB AT A GLANCE**

As the Head: Medical Management, you will be reporting to the General Manager: Claims and Medical Management. You will be responsible the implementation of the medical occupational management framework for compensation benefit processing and will be responsible for making strategic decisions with respect to the adjudication, assessment, and liability of the Medical Management department. You will also be responsible for organising, coordinating, and supervising the department towards greater functional efficiency and ensure the continuous improvement of policies and strategic direction in line with best practice. As well as develop, establish, and manage key support networks and provide the medical support to stakeholders. You will manage projects and programs and ensure the provision of medical advice and training to all stakeholders of Rand Mutual Assurance.

**WHAT WILL YOU DO?**

**Effective Medical management**
- Assume overall accountability for the authorisation of all claims and ensure medical support for claims management with respect to complex medical matters
- Provide medico-legal advice to operational processes so that disputes, repudiations, hearings, backlogs, and medical liability can be determined
- Guide investigations with respect to the acceptance of liability for high cost or complex medical accounts
- Provide technical advice and feedback on trends regarding treatment
- Maintain and continuously review medical claims policies and procedures
- Oversee the function’s daily operations and procedures as well as the overall efficiency of the Medical Department
- Ensure that processes, procedures, and systems to facilitate effective and efficient claims adjudication; medical advice; medical administration and medical operations are defined and adhered to using effective measurement tools
- Issue new directives and changed procedures to update operational and process efficiencies and control in line with best practice
- Ensure accurate reporting on all departmental objectives and outcomes
- Provide support and oversight of the rehabilitation function.

**Cost Management**
- Prepare and manage departmental budget
- Analyse medical spend and provider usage patterns
- Work with other executives on budgeting, forecasting, and resource allocation
- Manage medical provider service delivery to ensure quality and sustainable medical services at an affordable cost
- Ensure proper accounting records are maintained
- Oversee the correct cost evaluation of clinical elements for the processing of claims
- Monitor actual performance against budgets, forecasts, and projects
- Identify high risk, high-cost pensioners to assist proactively
- Ensure treatment plans fit individual needs
- Promote cost-effective health care regionally
- Motivate adherence to the National Health Reference Price List (NHRPL) rates for subsequent care
- Motivate for alternative reimbursement models

**Regulatory compliance and risk management**
- Ensure legislative compliance and compliance in all matters relating to medical claims, compensation, and treatment requirement
- Ensure proper reporting to the Compensation Fund and other relevant entities for purposes of regulatory compliance
- Ensure adherence to all relevant people management legislation, procedures, and policies.
- Ensure compliance and the management of risk actions for the department
- Develop and implement a return-to-work programme for claims
- Develop a Health and Safety programme in collaboration with employees ** Customer and stakeholder engagement and liaison**
- Ensure regular liaison and effective communication with HCP and provider network, sharing RMA requirements and preferences
- Represent the Medical Department at internal & external meetings when required
- Oversee the assessment of clinics in various regions upon instructions of the Compensation Commissioner
- Engage and maintain effective communication with internal and external stakeholders: both administrative and medical colleagues with the objective of enhancing understanding of medical treatment options, benefits, and procedures
- Provide feedback to colleagues on medical issues where appropriate

**Effective leadership and development of the Medical Management team**
- Oversee and support all units within the medical management department
- Ensure departmental leadership and alignment to the company’s strategic vision, values, and business plan
- Evaluate the performance of direct reports against contracted performance targets, identify performance and developmental gaps and agree on personal development plans
- Promote a spirit of equality and non-discrimination and ensure that policies are implemented fairly and consistently
- Develop and maintain a work environment that recruits, retains, and supports high performing employees
- Participate, and encourage sub-ordinates to participate, in seminars, workshops, and conferences and online learning as identified in pe

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