Active Jobs at Road Accident Fund

Key Performance Areas

Field Case Management

• Activate an undertaking certificate and compile a case management report.
• Conduct a home visit and educate the claimant on offerings of the undertaking and explain the process to be followed.
• Conduct follow up assessments and make recommendations on claimants needs as per the assessment.
• Coordinate the referrals to service providers aligned to the claimants needs as per the undertaking certificate.
• Ensure successful integration of the claimant back to the family and educate the claimant and family on the condition of the claimant.
• Facilitate timely consultation with appropriate medical service providers.
• Provide vocational guidance and possible back to work opportunities.

Rehabilitation Services

• Monitor the rehabilitation of claimant post discharge.
• Monitor the drug utilisation and application review thereof.
• Assess the level of care giver and the financial implications/ salary thereof. 
• Determine claimant needs and facilitate reasonable recommendations for home and car modifications based on the nature of the claimant’s medical condition.
• Coordination of admission and request the necessary authorisations as per the caregiver SOP and guidelines.
• Coordinate and facilitate transfer to the hospital for admission.
• Facilitate the appointment of caregivers between the claimant and the caregiver, provide guidance on the process. 
• Coordinate the monthly submission of time sheets for payment processing.

Facilitate the accuracy and effective submission of invoices

• Ensure that accounts submitted to the fund from service providers are valid in terms of RAF guidelines and the Road Accident Fund Act.
• Assess and monitor claims invoices to curb over servicing or abuse and fraudulent claims.
• Ensure that the accounts are paid timeously, according to service level agreements.
• Ensure that services and treatments claimed for are accident related (related to the accident under consideration).
• Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided is invaluable in developing guidelines for clinical management.

Reporting

• Compile and update Case management reports for the injured.
• Provide a report on patient care and ongoing rehabilitation.
• Reporting on the service by service providers.

Stakeholder management

• Drive the stakeholder interaction needed to facilitate the level of care.
• Maintain relations with different levels of health specialists to enable smooth interactions.
• Particate in the awareness of RAF case management services in the communities.
• Communicate with all levels of stakeholders.
• Participate in relevant external RAF activities and events. 
• Ongoing engagements with service providers.

Qualifications

• Bachelor’s Degree or Advanced Diploma in Nursing/ Allied Health Professions or related qualification.
• Registration with the relevant Health Professional Council body.

Experience

• Relevant 4 years’ experience in the medical environment.
• Experience in Managed Healthcare environment.
• Knowledge of ICD and CPT coding will be an advantage.
• Valid code 8 driving license.

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Key Performance Areas

Assessment of Injuries

• Assess extent of injuries on admitted patients.
• Daily assessment of patient according to prescribed measurements.
• Conduct daily patient scoring and data collecting.
• Monitor quality of care.
• Select and monitor clinical pathways.
• Identify patients’ needs.
• Identify and record pre-existing conditions.

Facilitate patient care

• Facilitate multi-disciplinary patient care where appropriate.
• Facilitate timely transfers into the appropriate levels of care.
• Coordinate the admission and pre authorisations of the transfers.
• Coordinate and provide necessary health education.
• Discharge planning and vocational guidance for the afterlife changing event for client
• Drug utilization review.
• Proper handover to Field Case Management for continuation of care.

Patient advocacy

• Cost Benefits analysis of the medical services.
• Liaison between patient and care team to ensure common understanding and conflict resolution.
• Negotiate and procure resource services from providers.
• Ensure that patient confidentiality is maintained by all parties.

Facilitate the accuracy and effective submission of invoices

• Ensure that accounts submitted to the fund from service providers are valid in terms of RAF guidelines and the Road Accident Fund Act.
• Assess and monitor claims invoices to curb over servicing or abuse and fraudulent claims.
• Ensure that the accounts are paid timeously, according to service level agreements.
• Ensure that services and treatments claimed for are accident related (related to the accident under consideration).
• Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided is invaluable in developing guidelines for clinical management.

Reporting

• Compile and update Hospital Case management reports.
• Recommend issuing of Undertaking Certificate.
• Provide a reasonableness report of patient care in preparation of the rehabilitation post discharge.

Stakeholder management

• Communicate with all levels of stakeholders.
• Participate in relevant external RAF activities and events.
• Ongoing engagements with service providers.

Qualifications

• Bachelor’s Degree or Advanced Diploma in Nursing/ Allied Health Professions or related qualification.
• Registration with the relevant Health Professional Council Body. 

Experience

• Relevant 4 years’ experience in the medical environment.
• Experience in Managed Healthcare.
• Knowledge of ICD and CPT coding will be an advantage.
• Valid code 8 driving license.

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Key Performance Areas

Compliance administration.

• Maintain up-to-date written documentation related to the department’s business activities.
• Ensure compliance to the policies and process standards.
• Keep abreast of internal standards and business goals to ensure adherence to sound internal control.

Office Coordination.

• Assist in making follow-ups on outstanding matters.
• Ensure all requests are handled and responded to within set timelines.
• Assist in ensuring the availability of stationery within the department.
• Validate and verify information and documents submitted for accurate capturing and further handling.
• Ensure the systems/registers used are kept up to date.
• Check for duplicate documents, requests and queries and report on them.
• Allocate reference numbers and accurately capture related documents on different systems.
• Allocation of matters to responsible team members.
• Draft and send out letters to all stakeholders as required.

Document and Records Management.

• Administer the records management and filling processes in line with the RAF filling plan
• Ensure that the filing system is always up-to-date and functional.
• Retrieval of information at all times as requested in the office.
• Ensure confidentiality of all documents under control and that documentation reaches the intended recipients.
• Acknowledge the receipt of documentation, apply a file number allocation, record data onto the computer system and file appropriately.

Meeting Support

• Assist in making follow-ups on outstanding matters.
• Ensure all requests are handled and responded to within set timelines.
• Assist in ensuring the availability of stationery within the department.
• Validate and verify information and documents submitted for accurate capturing and further handling.
• Ensure the systems/registers used are kept up to date.
• Check for duplicate documents, requests and queries and report on them.
• Allocate reference numbers and accurately capture related documents on different systems.
• Allocation of matters to responsible team members.
• Draft and send out letters to all stakeholders as required.
• Ensure confirmation of meetings and management of team diaries.
• Schedule appointments with internal and external stakeholders as and when required.

Qualifications and Experience

• Matric or Grade 12 certificate.
• Relevant 1 year experience in the Medical Administrative field or similar environment.
• Medical Field as an added advantage

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Key Performance Areas

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 RAF and / or any that is considered reasonable.
• Preauthorize submitted claims aligned to RAF clinical guidelines including the RAF 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 of an unusual occurrence procedure.

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 and make 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

• 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