Medical Claims Review Officer

2 weeks ago

Centurion, South Africa Nambiti Technologies Full time

We are recruiting for a Medical Claims Review Officer position.

**Key Performance Areas**
**Audit & review medical bills.**
- Analysis of claimed items/services in correlation with available tariff structures and ICD 10 /CPT 4 codes.
- Requesting motivation for unreasonable accounts.
- Line by line analysis of claim items/service. Matching those appropriate tariffs/ICD/CPT codes.
- Flagging rejected items/services.
- Recommendations to department responsible for processing payments.
- Auditing medical claims and assisting in technical aspects of bill review.
- Ensure that accounts submitted to the Fund from service providers are valid in terms of company guidelines and the Road Accident Fund Act.
- Assess and monitor claims to curb over servicing or abuse and fraudulent claims.
- Ensuring that the accounts are paid timeously according to the service level agreements.
- Ensure that the services and treatments claimed are accident related/ (related to the accident under consideration).
- Reduce future healthcare cost and improve efficiencies by analysing trends in in injured person’s use of services.
- Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided.
- Manage future healthcare costs and improve efficiencies by analysing trends in utilization of services.
- Formal assessment of medical necessity and appropriateness of procedures they will be in effective in curbing fraud and over servicing unreasonable demand of benefits from victims of road accidents.

**Promote good working relations with Stake Holders.**
- Check and advise on the tariffs used on accounts.
- Provided training on new developments.

**Approve medical expenses in accordance with relevant DOA.**
- Authorisation in accordance with mandate.
- Inform service provider of payment decision.

**Assisting in technical aspects of bill review.**
- Develop and manage relationships with department of health services, government dept and other key external stake holders.

**Check & approve Payments in terms of DOA.**
- Receive invoices and check payment request for accuracy and correctness.

**Determine the level of care based on functional ability.**
- Analysis of medical data available e.g. Case Manager’s Reports, Clinical Records and Medico - Legal Reports.

**Preauthorisation of procedures.**
- Analyse medical data to determine the need for the service.
- Timeous assessment of urgent files e.g. Road Shows.

**Qualifications**
- Bachelor’s Degree or Advanced Diploma in nursing/ Allied Health Professions or related qualification
- Registration with the relevant Health professions council.

**Experience**
- Relevant 3 years’ experience in a medical field.

**Competencies**
**Behavioural**:

- Personal mastery
- Emotional Wisdom.
- Ethics and Governance.
- Customer orientation and customer focus.

**Technical**:

- Computer literacy.
- Ability to interpret the rules of the UPFS tariffs.
- Analytical skills.
- Organisational & Administrative skills
- Planning and Organising
- Decision making
- Negotiation skills.

For more information please contact:
**Tebogo Rankhumise

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