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.