Consultant: Medical Management

Recruiter:

Nambiti Technologies

Job Ref:

JHB002672/TR

Date posted:

Wednesday, January 29, 2025

Location:

Capetown, South Africa

SUMMARY:
We are recruiting for a consultant: Medical Management position.

POSITION INFO:

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.

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