Purpose of the Job: The Manager: Medical Management is accountable to manage the medical management capability in supporting the claims operations
Key Performance Areas Policy Review and Implementation Contribute to the development and implementation of claims medical operations policy, procedures and processes. Keep up to date with effective claims operations policy and practice execution strategies. Medical Management Manage medical assessments including injury assessments of past and future medical care, preauthorization and clinical coding. Manage the assessment of the seriousness of medical injuries and determination of future care. Manage the implementation of the tariff, cost savings initiative recording and treatment protocol to ensure that all service providers adhere to the rules, and the tariff as guided by the RAF. Review assessment reports and provide recommendations. Exception handling Develop tracking methods to report analysis results in business case scenarios. Manage the development and maintenance of formal exception handling process within the medical management unit. Management of supporting policies and procedures in line with managing exception handling with the division • Represent the Fund in relevant Reporting Prepare and submit regulation reports as and when required to provide progress updates and/or inform management decisions. Develop reports/ policies/ procedures and guide the process through the alignment of the documents to the overall RAF's Strategy. Stakeholder management Facilitate and manage communication with relevant internal and external stakeholders proactively and progressively manage the relationships. Communicate with all levels of stakeholder contact. Represent the Fund in relevant external activities and events. People Management Facilitate and manage communication with relevant internal and external stakeholders proactively and progressively manage the relationships. Communicate with all levels of stakeholder contact. Represent the Fund in relevant external activities and events. Qualifications and Experience Bachelor's Degree/Advanced Diploma in Health Sciences or Medical related qualification. Postgraduate in a Health Sciences or Medical related qualification will be an added advantage. Registration with HPCSA/SANCA. Relevant 6-8 years' experience in a Medical Management related environment of which 2 (two) years must have been on a management/supervisory level/area of expertise. Technical and Behavioral Competencies Required Resilience Communication Working with People Network and Alliances Planning, Organising and Coordinating Employee Engagement Personal Mastery Ethics and Values Client Service Orientation Judgement and decision making Change management Coaching and mentoring Conflict management Critical and innovative thinking Direction setting Facilitation and Presentation Skills People management Policy conceptualisation and formulation Risk Management Programme/project management Service Delivery Innovation Stakeholder development and relations Claims management process/ processes and systems. Medical Management Medical bill reviewing Medical case management Complex problem identification, solving and decision making Customer value proposition Good financial management skills Strong analytical capabilities Knowledge of Motor Vehicle Accident legislation PFMA knowledge Reporting 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".
