Consultant: Medical Management
Menlo Park, Gauteng, ZA
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: The Consultant: Medical Management is responsible 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, 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.
- Pre-authorise 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
Qualifications and Experience
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Technical Competencies Required
- Claims management process/processes and systems.
- Medical product management.
- Medical bill reviewing
- Medical case management
Behavioural Competencies Required
- Planning, Organising and Coordinating
- Personal mastery
- Judgment and decision making
- Ethics and Values
- Client Service Orientation
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.