Specialist: Bill Review

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.

Purpose of the Job: Reporting to the Manager: Medical Advisory, the successful incumbent is accountable to review medical bills, to provide input to the development of treatment protocols in line with the scope of practice of Registered/ Professional Nurses. As part of the clinical research and treatment policy team, this role applies clinical knowledge to assess and ensure services/ items billed are reasonable and necessary as per applicable policies and procedures.

Key Performance Areas

Development of Bill Review Rules and Guidelines

• Provide input into the development of guidelines to review medical bills in accordance to the fee schedule and internal processing guidelines.
• Research into the RAF Serious injury, the relevant CPT and ICD codes, unit standards and cost.
• Identify all the relevant medical codes (ICD 10, CPT, Tariffs, etc) which need to be updated, within bill review scope.
• Updating the Bill Review rules in collaboration with the clinical research team.

Audit and Review Medical Bills

• Accuracy of Bill review standards on cross-walked ICD and CPT application on invoice assessments.
• Report on bill reviewed cases for the organization, and cost containment.
• Provide information relating to claims process and procedure.
• Specify and report on manual bill review and later automated bill reviewed cases.
• Support in the identification, development and implementation of cost-effective processes in order to increase efficiency and reduce cost drivers related to the area of specialization.

Provide Input into Treatment Protocols

• Participate in the development of basket of care and its alternatives for each individual treatment plans/ protocols.
• Provide inputs to development of treatment plans/ protocols and crosswalks.
• Identify relevant treatment plans and gaps in bill review and provide the feedback to Senior Medical Manager to update treatment protocols.

Policy Review and Implementation

• Contribute to the development and implementation of developmental policy, procedures and processes.
• Keep up to date with effective SOP’s, policy and practice execution strategies.

Reporting

• Prepare and submit regulation reports as and when required to provide progress updates and/or inform management decisions.
• Develop reports/ procedures and guide the process through the alignment of the documents to the overall RAF’s Strategy.
• Develop functional reporting systems, for management, projects or performance reporting.

Provide Support to Bill Reviewers

• Provide bill review clinical and technical support.
• In collaboration with L&D, ensure updated and standardised training of Bill Reviewers.
• Support the bill review team in complicated queries.
• Manage and create productivity management tool for bill reviewers.
• Develop quality management tool /sampling tool to monitor work of bill reviewers. 

Stakeholder Management

• Facilitate and manage communication with relevant internal and external stakeholders in relation to investments and proactively and progressively manage the relationships.
• Manage relationships with vendors, service providers or procurement teams and ensure that all relevant procured items are invoiced and paid on time.

Qualifications and Experience

• Bachelor’s Degree/ Advanced Diploma in Nursing related qualification.
• Valid Registration with the SANC as a Registered Nurse.
• Qualification in Critical care/ Emergency care/ Theatre technique will be advantageous.
• Relevant 5 - 7 years’ experience in an ICU Unit/ High Care/ Emergency Unit of a multidisciplinary hospital or Medical Scheme environment.
• With experience in working with ICD 10 codes, CPT codes, NAPPI codes, tariffs, and all modalities of treatment in ICU, theatre, and ward. 

Technical and Behavioral Competencies Required

• Resilience.
• Network and alliance.
• Employee engagement.
• Ethics and values.
• Change management.
• Critical and innovative thinking
• Policy conceptualisation and formulation.
• Risk Management.
• Stakeholder development and relations.
• Reporting.
• An understanding of the applicable rules to service providers with regards to their scope of practice and the maximum charge.
• Ability to understand unit standards, per service provider and management of exceptions by treating doctors.
• Working knowledge of medical claims, related charges, and clinical audit of claims.
• Vast knowledge of MVA and related complications.
• Knowledge and understanding of new technologies in the rehabilitation process.
• Ability to work and create crosswalks for system development.

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.