Senior Medical Management Specialist
4 weeks ago
Nambiti Technologies is seeking an experienced Senior Medical Management Specialist to join our team.
The ideal candidate will have a strong background in medical management, with at least 3 years of experience in a related environment. They will be responsible for implementing medical management activities, handling exceptions, and providing administration support in claims processing.
Key Responsibilities:
- Medical Management
- Conduct medical assessments 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 initiatives, and treatment protocols to ensure adherence to company guidelines.
- Pre-authorise submitted claims aligned to company clinical guidelines, including formulary, treatment protocols, and related tariffs.
- Escalate complex cases for multi-disciplinary review and adjudication.
- Participate in consultations on the implementation of medical claims processes.
- Exception Handling
- Implement and maintain a formal exception handling process within medical management.
- Maintain documentation and update the exception handling process regularly.
- Maintain an unusual occurrence procedure.
- 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 queries, making recommendations on corrective actions.
- Follow up and feedback to stakeholders on query status.
- Respond to queries within predefined turnaround times.
Requirements:
- Bachelors Degree or Advanced Diploma in Health Sciences or Medical-related qualification.
- Registration with HPCSA/SANCA.
- Relevant 3 years of experience in a Medical-related environment.
- Technical and behavioral competencies required, including claims management, medical product management, medical bill reviewing, and medical case management.
- Strong clinical analytical capabilities, knowledge of motor vehicle accident legislation, planning, organizing, and coordinating.
- Judgement and decision-making, ethics, and values, client service orientation.
About the Role:
This role offers a competitive salary of $80,000 - $110,000 per annum, depending on experience. The successful candidate will also receive comprehensive benefits, including health insurance, retirement plan, and paid time off.
Estimated Salary: $90,000 per annum
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