Medical Management&Claims Consultant, Pretoria

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 exceptionhandling 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.

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