Consultant: Medical Management x 7

The Road Accident Fund’s mission is to provide appropriate cover to all road users within the borders of South Africa; to rehabilitate and compensate persons injured as a result of motor vehicle accidents in a timely and caring manner; and to actively promote safe use of our roads.

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”

The Road Accident Fund subscribes to the principles of employment equity and preference will be given to People with Disabilities.

Applicants who have not received any correspondence from us within six weeks from the closing date can consider themselves unsuccessful

Security Vetting shall be conducted on all prospective employees

It is the applicants’ responsibility to have foreign qualification evaluated by the South African Qualification Authority (SAQA) and to provide proof of such evaluation.