Note: This is a 12-month, fixed-term contract position Purpose of the job: The Consultant: Future Medical Adjudication is responsible for the verification of eligibility for claims to be paid out based on future medical findings.
Key Performance Areas Future medical adjudication • Check and activate pre-defined injury specific undertaking from accident information Centre.
• Confirm and record medical management recommendations.
• Develop and issue injury specific undertaking to the qualifying claimant and apply court outcomes
where required.
• Quantify the cost of the developed injury specific undertaking.
• Check developed treatment / rehab plan / injured needs and develop specified undertaking/offer
certificate.
• Approve offer in line with the DOA.
• After approval, communicate FME certificate to the claimant through offer management department.
Quality assurance • Participate in the consultations process on the implementation of claims and related processes.
• Ensure that claims and processes are implemented and maintained at the highest standards.
• Maintain the implementation of unusual occurrence procedures.
• Ensure the accurate quantification of future medical expenses.
Administrative support • Deal with/and respond to correspondence.
• Produce documents, briefing papers, reports, and presentations.
• Assist with typing and editing briefs, technical papers, letters to various parties, and memos.
Reporting • Track and report against set objectives and targets.
• Report on emerging risks.
• Provide ad hoc reports on process improvement initiatives.
Stakeholder management • Maintain healthy relationships with all stakeholders.
• Follow up and resolve all queries, following up and making 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 a Health Sciences related qualification to discipline.
• Registration with SANCA
Experience • Relevant 3 years' experience in a claims adjudication related environment.
Technical and behavioral competencies required • Knowledge of tariffs: National Health Reference Price List (NHRPL) and Uniform Patient Fee
Schedule (UPFS).
• Knowledge of procedure and treatment codes: ICD 10 and CPT4.
• Basic understanding of managed health care industry in South Africa.
(Medical claims and charges).
• Claims assessment and settlement process and systems (including handling, general damages
assessment and settlement)
• Claims management process/ processes and systems (including handling, verification and validation,
investigation, assessment/settlement, litigation, legal costs assessment and settlement)
• Medical case management
• Complex problem identification, solving and decision making.
• Claims management processes and systems
• Customer value proposition
• Good financial management skills
• Strong analytical capabilities
• Planning, Organising and Coordinating
• Personal Mastery
• Judgement and Decision Making
• Ethics and Values
• Client Service Orientation
NB: "RAF offers Total Employment Cost packages with no additional contributions from the Employer, successful candidates are required to structure their packages in a manner that will suit their needs." Note: This is a 12-month, fixed-term contract position Purpose of the job: The Consultant: Future Medical Adjudication is responsible for the verification of eligibility for claims to be paid out based on future medical findings.
Key Performance Areas Future medical adjudication • Check and activate pre-defined injury specific undertaking from accident information Centre.
• Confirm and record medical management recommendations.
• Develop and issue injury specific undertaking to the qualifying claimant and apply court outcomes
where required.
• Quantify the cost of the developed injury specific undertaking.
• Check developed treatment / rehab plan / injured needs and develop specified undertaking/offer
certificate.
• Approve offer in line with the DOA.
• After approval, communicate FME certificate to the claimant through offer management department.
Quality assurance • Participate in the consultations process on the implementation of claims and related processes.
• Ensure that claims and processes are implemented and maintained at the highest standards.
• Maintain the implementation of unusual occurrence procedures.
• Ensure the accurate quantification of future medical expenses.
Administrative support • Deal with/and respond to correspondence.
• Produce documents, briefing papers, reports, and presentations.
• Assist with typing and editing briefs, technical papers, letters to various parties, and memos.
Reporting • Track and report against set objectives and targets.
• Report on emerging risks.
• Provide ad hoc reports on process improvement initiatives.
Stakeholder management • Maintain healthy relationships with all stakeholders.
• Follow up and resolve all queries, following up and making 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 a Health Sciences related qualification to discipline.
• Registration with SANCA
Experience • Relevant 3 years' experience in a claims adjudication related environment.
Technical and behavioral competencies required • Knowledge of tariffs: National Health Reference Price List (NHRPL) and Uniform Patient Fee
Schedule (UPFS).
• Knowledge of procedure and treatment codes: ICD 10 and CPT4.
• Basic understanding of managed health care industry in South Africa.
(Medical claims and charges).
• Claims assessment and settlement process and systems (including handling, general damages
assessment and settlement)
• Claims management process/ processes and systems (including handling, verification and validation,
investigation, assessment/settlement, litigation, legal costs assessment and settlement)
• Medical case management
• Complex problem identification, solving and decision making.
• Claims management processes and systems
• Customer value proposition
• Good financial management skills
• Strong analytical capabilities
• Planning, Organising and Coordinating
• Personal Mastery
• Judgement and Decision Making
• Ethics and Values
• Client Service Orientation
NB: "RAF offers Total Employment Cost packages with no additional contributions from the Employer, successful candidates are required to structure their packages in a manner that will suit their needs."
