Consultant: Medical Management x 7

3 weeks ago


Cape Town, South Africa Road Accident Fund Full time

NB: This is a 12 Month’s Fixed Term Contract Position

 

Purpose of the Job: To implement the medical management activities, medical exception handling and providing administration support in claims processing.

 

 


NB: This is a 12 Month’s Fixed Term Contract Position

 

Purpose of the Job: To implement the medical management activities, medical exception handling and providing administration support in claims processing.

 

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, 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 formularory, 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, following up and making 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 and Experience       

  • Bachelor’s degree/Advanced Diploma in Health Sciences /Medical related qualification.
  • Registration with HPCSA/SANCA.
  • Related 3 years’ experience in a Medical related environment.

 

Technical and behavioral competencies required

  • Planning, Organising and Coordinating
  • Personal Mastery
  • Judgement and Decision Making
  • Ethics and Values
  • Client Service Orientation
  • 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.

 

Road Accident Fund Values

  • Integrity
  • Compassion
  • Accountability
  • Respect
  • Excellence

 

NB: “RAF offers Total Employment Cost packages with no additional contributions from the Employer, successful candidates are required to structure their packages in a manner that will suit their needs”

 



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