Consultant: Medical Management

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.

• 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.

• 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.

• Bachelor’s Degree/Advanced Diploma in Health Sciences/ Medical related qualification.
• Registration with HPCSA/SANCA

• 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.