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  • Posted: Jan 19, 2021
    Deadline: Not specified
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    • RMA in a nutshell Identifying a need to help care for miners who were injured while on duty, Rand Mutual (RMA) was founded in 1894 by three mining companies on the Witwatersrand as a non-profit mutual assurance company. Today RMA has grown to offer workmens'​ compensation benefits to the mining, iron, metal, steel and relate...
    Read more about this company

     

    Head of Medical

    Purpose of the role

    • Reporting into the General Manager: Claims and Medical Management the incumbent will be accountable for the implementation of the medical occupational management framework for compensation benefit processing and will be responsible for making strategic decisions concerning the adjudication, assessment, and liability of the Medical Management department.

    Qualifications and experience required:

    • Medical Degree (MBChB)
    • NQF Level 9: Master’s Degree in an Accredited Healthcare or Insurance Qualification -
    • Master of Business Administration preferably in Health Care Leadership or Postgraduate Medical Management Qualification (preferred)
    • Occupational Health qualification diploma /degree (DOH)
    • At least 10 years of relevant clinical experience
    • At least 5 years of managerial experience in the healthcare insurance, occupational health, and/or compensation environment
    • Registration with a recognised Healthcare Provider Association

    Key Areas of Responsibility:

    • Organising, coordinating, and supervising the department towards greater functional efficiency and ensure the continuous improvement of policies and strategic direction in line with best practice
    • Develop, establish, and manage key support networks and provide the medical support to stakeholders.
    • Manage projects and programs and ensure the provision of medical advice and training to all stakeholders of Rand Mutual Assurance.
    • Effective medical management
    • Assume overall accountability for the medical authorisation and management of all claims and ensure medical support for claims management with respect to complex medical matters
    • Provide medico-legal advice to operational processes so that disputes, repudiations, hearings, backlogs, and medical liability can be determined
    • Guide investigations with respect to the acceptance of liability for high cost or complex medical accounts
    • Provide technical advice and feedback on trends regarding treatment
    • Maintain and continuously review medical claims policies and procedures
    • Oversee the function’s daily operations and procedures as well as the overall efficiency of the Medical Department
    • Ensure that there are processes, procedures, and systems to facilitate effective and efficient medical claims adjudication and management, and adherence by using effective measurement tools
    • Issue new directives and changed procedures to update medical operational and process efficiencies and controls in line with best practice
    • Ensure accurate reporting on all departmental objectives and outcomes
    • Cost Management
    • Prepare and manage departmental budget
    • Analyse medical spend and provider usage patterns
    • Work with other executives on budgeting, forecasting, and resource allocation
    • Manage medical provider service delivery to ensure quality and sustainable medical services at an affordable cost
    • Ensure proper accounting records are maintained
    • Oversee the correct cost evaluation of clinical elements for the processing of claims
    • Monitor actual performance against budgets, forecasts, and projects
    • Identify high risk, high-cost pensioners to assist proactively
    • Ensure treatment plans fit individual needs
    • Promote cost-effective health care regionally
    • Motivate adherence to the National Health Reference Price List (NHRPL) rates for subsequent care
    • Motivate for alternative reimbursement models
    • Regulatory compliance and risk management
    • Ensure legislative compliance and compliance in all matters relating to medical claims, compensation, and treatment requirement
    • Ensure proper reporting to the Compensation Fund and other relevant entities for purposes of regulatory compliance
    • Ensure adherence to all relevant people management legislation, procedures, and policies
    • Ensure compliance and the management of risk actions for the department
    • Develop and implement a return to work programme for claims
    • Develop a Health and Safety programme in collaboration with employees
    • Customer and stakeholder engagement and liaison
    • Ensure regular liaison and effective communication with HCP and provider network, sharing RMA requirements and preferences
    • Represent the Medical Department at internal & external meetings when required
    • Oversee the assessment of clinics in various regions upon instructions of the Compensation Commissioner
    • Engage and maintain effective communication with internal and external stakeholders: both administrative and medical colleagues to enhance understanding of medical treatment options, benefits, and procedures
    • Provide feedback to colleagues on medical issues where appropriate
    • Effective leadership and development of the Medical Management team
    • Oversee and support all units within the medical management department
    • Ensure departmental leadership and alignment to the company’s strategic vision, values, and business plan
    • Evaluate the performance of direct reports against contracted performance targets, identify performance and developmental gaps and agree on personal development plans
    • Promote a spirit of equality and non-discrimination and ensure that policies are implemented fairly and consistently
    • Develop and maintain a work environment that recruits retains, and supports high performing employees
    • Participate, and encourage subordinates to participate, in seminars, workshops, and conferences and online learning as identified in personal development plans
    • Keep abreast of emerging trends in health care delivery; identify and define new and innovative strategies to achieve organisational goals and objectives
    • Grow and maintain a strong medical community of practice and cultivate a learning culture amongst medical and administrative colleagues

    Knowledge, Skills and Competencies required:

    • Proficiency in Microsoft office 
    • Principles of Managed Health Care
    • Occupational Health Risk Management
    • Compensation for Occupational Injuries and Diseases Act
    • Occupational Diseases in Mines and Works Act (preferable)
    • Knowledge of managed care
    • Mine Health and Safety Act (preferable)
    • Occupational Health & Safety Act
    • Knowledge of medical claims management policies, procedures, systems, and processes
    • Leading and supervising
    • Managing performance
    • Judgment and decision-making
    • Complex problem solving
    • Persuading and Influencing
    • Process engineering and systems competence
    • Commercial orientation

    Method of Application

    Interested and qualified? Go to Rand Mutual - RMA on randmutual.co.za to apply

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