Note: This is a 12-month, fixed-term contract position Purpose of the job: The Consultant: Past Medical Adjudication is responsible for the verification of eligibility for claims to be paid out based on past medical outcomes.
Key Performance Areas Past medical adjudication Receive and record medical management bill review assessment outcome. Perform duplicate, mortality and prescriptions checks. Receive invoices and check payment requests for accuracy and correctness. Load payment request. Make an offer on available voucher and apply contingencies where applicable. Check substantial compliance with RAF Act. 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 an unusual occurrence procedure. Administrative support Deal with/and respond to correspondence. Produce documents, briefing papers, reports, and presentations. Taking dictation and minutes, letters to various parties, and memos. Assist with typing and editing briefs, technical papers, letters to various parties, and memos. Screen phone calls, inquiries, and requests. 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 related qualification. 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) 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 Knowledge of Motor Vehicle Accident legislation PFMA knowledge 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: Past Medical Adjudication is responsible for the verification of eligibility for claims to be paid out based on past medical outcomes.
Key Performance Areas Past medical adjudication Receive and record medical management bill review assessment outcome. Perform duplicate, mortality and prescriptions checks. Receive invoices and check payment requests for accuracy and correctness. Load payment request. Make an offer on available voucher and apply contingencies where applicable. Check substantial compliance with RAF Act. 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 an unusual occurrence procedure. Administrative support Deal with/and respond to correspondence. Produce documents, briefing papers, reports, and presentations. Taking dictation and minutes, letters to various parties, and memos. Assist with typing and editing briefs, technical papers, letters to various parties, and memos. Screen phone calls, inquiries, and requests. 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 related qualification. 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) 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 Knowledge of Motor Vehicle Accident legislation PFMA knowledge 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."
