Medical Claims Review Officer

SUMMARY:
We are recruiting for a Medical Claims Review Officer position.

POSITION INFO:
Key Performance Areas
Audit & review medical bills.

• Analysis of claimed items/services in correlation with available tariff structures and ICD 10 /CPT 4 codes.
• Requesting motivation for unreasonable accounts.
• Line by line analysis of claim items/service. Matching those appropriate tariffs/ICD/CPT codes.
• Flagging rejected items/services.
• Recommendations to department responsible for processing payments.
• Auditing medical claims and assisting in technical aspects of bill review.
• Ensure that accounts submitted to the Fund from service providers are valid in terms of company guidelines and the Road Accident Fund Act.
• Assess and monitor claims to curb over servicing or abuse and fraudulent claims.
• Ensuring that the accounts are paid timeously according to the service level agreements.
• Ensure that the services and treatments claimed are accident related/ (related to the accident under consideration).
• Reduce future healthcare cost and improve efficiencies by analysing trends in in injured person’s use of services.
• Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided.
• Manage future healthcare costs and improve efficiencies by analysing trends in utilization of services.
• Formal assessment of medical necessity and appropriateness of procedures they will be in effective in curbing fraud and over servicing unreasonable demand of benefits from victims of road accidents.

• Check and advise on the tariffs used on accounts.
• Provided training on new developments.

• Authorisation in accordance with mandate.
• Inform service provider of payment decision.

• Develop and manage relationships with department of health services, government dept and other key external stake holders.

• Receive invoices and check payment request for accuracy and correctness.

• Analysis of medical data available e.g. Case Manager’s Reports, Clinical Records and Medico - Legal Reports.

• Analyse medical data to determine the need for the service.
• Timeous assessment of urgent files e.g. Road Shows.

• Bachelor’s Degree or Advanced Diploma in nursing/ Allied Health Professions or related qualification
• Registration with the relevant Health professions council.

• Relevant 3 years’ experience in a medical field.

• Personal mastery
• Emotional Wisdom.
• Ethics and Governance.
• Customer orientation and customer focus.

• Computer literacy.
• Ability to interpret the rules of the UPFS tariffs.
• Analytical skills.
• Organisational & Administrative skills
• Planning and Organising
• Decision making
• Negotiation skills.