Our client is recruiting for a Consultant: Medical Management who will be responsible for implementing the medical management activities, medical exception handling and providing administrative support in claims processing.
DUTIES & RESPONSIBILITIES
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 organization and / or any that is considered reasonable.
- Pre authorise submitted claims aligned to the organization’s clinical guidelines including the 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 procedures.
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, 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.
DESIRED EXPERIENCE & QUALIFICATION
Qualifications
- Bachelor’s Degree/Advanced Diploma in Health Sciences /Medical related qualification.
- Registration with HPCSA/SANCA.
Experience
- Relevant 3 years’ experience in a Medical related environment.