Consultant: Medical Management X 22 at Road Accident Fund

Key Performance Areas

Medical management

Conduct medical assessment and compile injury assessment reports and compile injury assessment reports by means of:

• Analyse recorded injuries against the reported data on the accident information centre for alignment and to record the findings.
• Determine to which injury list does the recorded injury falls under and handle the assessment accordingly in line with the classisfication of the injury.
• Conduct assessments and bill reviews on submitted claims, focusing on the appropriate level of care, the  length of stay, and quality of care.
• Assessment of medical reports to identify the seriousness of the injuries and based on the findings,recommend the issue of the undertaking Certificate or refer for applicable product adjudication (General Damages and loss of Earning) for further handling.
• 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 RAF and/or any that is considered reasonable
• Pre-authorise submitted claims aligned to RAF clinical guidelines including the RAF formulatory, 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.

Qualifications and Experience       

• Bachelor’s degree/Advanced Diploma in Health Sciences /Medical related qualification.
• Registration with HPCSA/SANCA.
• Related 3 years’ experience in a Medical related environment.