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 Bachelors 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.