SUMMARY:
We are recruiting for a consultant: Medical Management position.
POSITION INFO:
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 company and / or any that is considered reasonable.
- Pre-authorise submitted claims aligned to company clinical guidelines including the company 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 procedure.
- 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 behavioural 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.
