Job Category: Management
Job Type: 12 Months FTC
Location: Johannesburg
Salary: R501 775 per annum
Purpose of the Job
The Consultant: Medical Management will be responsible for implementing medical management activities, handling medical exceptions, and providing administrative support in claims processing.
Key Performance Areas
Medical Management
- Conduct medical assessments and compile injury assessment reports.
- Review assessments and bills on submitted claims, focusing on quality of care, appropriate level of care, and length of stay.
- Ensure adherence to tariffs, treatment protocols, and cost-saving initiatives.
- Pre-authorise claims aligned to clinical guidelines, treatment protocols, and tariffs.
- Escalate complex cases for multidisciplinary review and adjudication.
- Participate in consultations on the implementation of medical claims processes.
Exception Handling
- Implement and maintain a formal exception handling process.
- Document and regularly update exception handling procedures.
- Maintain unusual occurrence reporting procedures.
Reporting
- Track and report on objectives and targets.
- Report on emerging risks and provide ad hoc reports on process improvement initiatives.
- Produce documents, briefing papers, reports, and presentations.
Stakeholder Management
- Respond to correspondence and maintain healthy relationships with stakeholders.
- Follow up and resolve queries within agreed turnaround times.
- Provide feedback and recommendations to ensure effective communication with stakeholders.
Minimum Requirements
- Bachelor’s Degree/Advanced Diploma in Health Sciences / Medical-related qualification.
- Registration with HPCSA or SANCA.
- Minimum of 3 years’ relevant experience in a medical-related environment.
Technical & Behavioural Competencies
- Claims management processes and systems.
- Medical product management and bill reviewing.
- Medical case management.
- Strong clinical analytical capabilities.
- Knowledge of motor vehicle accident legislation.
- Complex problem-solving and decision-making skills.
- Client service orientation, ethics, and values.
- Planning, organising, and coordinating skills.
For more info , Please contact Refiloe 0836528035