The Road Accident Fund is a state insurer established by statute, it provides insurance cover to all drivers of motor vehicles in South Africa in respect of liability incurred or damage caused as a result of a traffic collision. Liability incurred in relation to property damage (such as damage to vehicles, buildings, vehicle contents) is excluded from cover.
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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.
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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
Policy review and implementation
- Contribute to the development and implementation of departmental policy, procedures and processes.
- Keep up to date with effective policy and practice execution strategies
Manage effective workspace and parking space management.
- Create functional effective and flexible working areas.
- Maintain a database of accurate drawings of offices and submit any amendments to project office.
- Manage the allocation of parking bays and ensure compliance.
- Handle parking and workspace queries and ensure resolution.
Administration of audit and risk findings identified in the department
- Respond to the operational risks identified.
- Continuously monitor opportunities and incidents.
- Review audit findings, develop plans and submit comments to Senior Manager.
- Pro-actively rectify and control weaknesses identified.
- Ensure the proper administration, governance and risk management.
Manage Facilities services sectional budget and other financial resources management.
- Monitor the budget spending, manage the divisional cash flow and minimise budget variance.
- Forecast facilities management budget each FY starting with zero based and submit to manager.
- Ensure that expenses fall and are covered under the budget set.
- Ensure regular and consistent reporting on budget expenditure.
- To make input into the strategic and business planning and ensure budgeting for facilities services.
Manage 30-day payment of all FM invoices.
- Manage payment of accounts, rent and other Facilities Management related services.
- Manage landlords, agents on outstanding invoices before month end.
- Submit a report to manager on all invoice related information.
Manage all Facilities related Contracts.
- Draft memorandums and advise procurement of required Facilities Management contracts to ensure no irregular contracts.
- Manage service level agreements with service providers for office cleaning. Fumigation, office plant and special server room clearing etc.
- Ensure up to date contract data base.
Reporting
- Develop reports/ policies/ procedures and guide the process through the alignment of the documents to the overall RAF’s strategy.
- Develop functional reporting systems, for management, projects or performance reporting.
- Prepare proposals, briefings, presentations, reports, and other documentation and provide management information both verbally and in report format.
Stakeholder management
- Facilitate and manage communication with relevant internal and external stakeholders and proactively and progressively manage the relationships.
- Manage relationships with vendors, service providers or procurement teams and ensure that all relevant procured items are invoiced and paid on time.
- Communicate with all levels of stakeholder contact.
- Represent the Fund in erlavant external activities and events.
People Management
- Ensure the sourcing, development and retention of a high-performance team.
- Manage the recruitment of the operational workforce in line with employment equity targets.
- Manage staff in the department to ensure that they achieve their objectives in line with the strategic objectives of the RAF.
- Manage the implementation of people management processes and procedures to control/regulate workplace conflict and/or institute corrective measures and consultation processes to address deviations from standards.
- Allocate, direct, motivate and evaluate subordinates to help them achieve their individual goals.
Qualifications & Experience
- Bachelor’s Degree/Advanced Diploma in Facilities Management related qualification.
- Postgraduate in Facilities Management related qualification will be advantageous.
- Driver’s License.
- Relevant 6-8 years’ experience in Facilities management environment of which 2 years must have been on supervisory level/area of expertise/management level.
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Key Performance Areas
Claims Handling
- Ensure the correctness of the interpretation of the settlement, the undertaking, any limitations and or the past medical expenses to determine the Funds liability for future costs to be incurred.
- Ensure that any discrepancies are corrected by the redrafting of the undertaking to reflect the correct liability.
- Ensure that cognisance is taken of all expert reports, of internal and external origin, as well as the Medical and Legal assessment to determine the Funds liability for the costs incurred.
- Pre-authorise costs still to be incurred in terms of the undertaking within the mandate and in line with the medical and legal assessment.
- Recommend or approve payment of the costs as per the mandate; or repudiate the costs; or request more information or refer for medical intervention.
- Ensure that matters are referred to field Case Managers for further investigation.
- Ensure that the need for home visits are timeously identified and attended to when required.
- Ensure that the appropriate experts are appointed to do further assessments.
- Ensure the accurate quantification of undertakings.
Perform undertakings information audit
- Ensure the update in any change in the settlement details on the undertaking system to ensure that the liability of the Fund is accurately reflected on the system.
Ensure appropriate Correspondence on undertakings
- Ensure the drafting of legally correct correspondence to all external stakeholders.
- Ensure the drafting of legally correct contracts for the quantification of Undertakings.
- Ensure the drafting of legally correct contracts for the partial and/or buy-out and new undertaking.
- Ensure the re-issue of legally correct undertakings.
Perform advisory function
- Ensure that queries from internal and/or external stakeholders pertaining to the undertaking are attended to timeously & correctly.
- Ensure that stakeholders are given legally sound advice on legal issues pertaining to undertakings.
Litigation
- Ensure that the Fund is not prejudiced by way of litigation instituted in terms of the undertaking.
- Ensure that Management is timeously informed of any risk to prevent any prejudice.
- Ensure that the Funds attorneys act in line with the Funds policies.
Collate and compile statistics
- Keep daily stats of activities on Undertakings and related matters.
- Compile daily and monthly reports as required
- Keep record of the statistics.
Office administration
- Ensure that all matters are properly pended and followed up timeously.
- Ensure that all matters allocated are recorded.
- Ensure that all litigated matters are recorded.
- Ensure that all incoming correspondence are scrutinized and ensure that proper record is kept thereof.
- Ensure that proper record is kept of files requested and returned to the I/S, referred to Medical and/or Administration cell.
- Keep proper record of all complaints received and attended to.
- Keep proper record of all reports/memorandums/instructions etc.
- Control and query telephone lists on a monthly basis.
- Monitor staff availability on a daily basis.
Human Resources
- Identify training needs of personnel and satisfies those needs by means of direct training or refer to a third party to do the training.
- Ensure that all staff are informed of new directives, policies, guidelines, instructions.
- Ensure that staff follow and abide by the conditions of service.
- Ensure that claims received a dealt with timeously and correctly.
- Manage staff availability.
- Performs the necessary inspections and controls on files and computer records.
- Assess and appraise the performance of subordinated on a continuous basis.
Qualifications
- Bachelor’s Degree @ NQF Level 7 in law or equivalent.
Experience
- Relevant 4 years’ experience in the claims environment of which 1 year is on supervisory level
- Admitted as an attorney in a legal practice and basic knowledge of medical terminology will be advantageous.
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Key Performance Areas
Handle Claims
- Interpret the settlement, the undertaking and any limitations to determine the Funds liability for future costs to be incurred.
- Scrutinize past medical expenses to determine the Funds liability for future costs to be incurred.
- Identify any differences between the final settlements and re-draft the undertaking to reflect the correct liability.
- Take cognisance of all expert reports, of internal and external origin, to determine the following:
- The nexus between the costs incurred and the accident.
- The reasonability of the costs by comparing the costs incurred with the claimants personal circumstances and needs
- Communicate with experts where there is uncertainty i.r.o. costs incurred.
- Report any discrepancies to Senior Officer.
- Pre-authorise costs still to be incurred in terms of the undertaking within the mandate and in line with the medical and legal assessment.
- Recommend or approve payment of the costs as per the mandate; or repudiate the costs; or request more information or refer for medical intervention.
- Refer cases to field Case Managers for further investigation
- Determine the need for home visits and attend when required.
- Determine the need for the appointment of experts to do further assessments.
- Approve other officers payments on MIS which includes checking for duplicates and if the correct payee is being paid.
Update claims records
- Correct/update any change in the settlement details on the undertaking system to ensure that the liability of the Fund is accurately reflected on the system.
Manage Correspondence
- Draft legal correspondence to all external stakeholders.
Attend to queries
Attend to queries from internal and external stakeholders pertaining to the undertaking including the following:
- Liability of the Fund in terms of the undertaking.
- How to submit a claim.
- Status/progress made on the claims already submitted.
- General enquiries.
- Give advice to stakeholders on legal issues pertaining to undertakings.
Manage Litigation
- Receive & record all litigation processes served in terms of the Undertaking.
- Evaluate the documents, consider the Funds legal position with regards to the process.
- Arrange for the matter to be held over, if necessary, alternatively.
- Appoint an attorney for the Fund to defend the matter.
- Refer the matter for assessment to determine the Funds liability.
- Negotiate settlement with the attorney, alternatively, consider the opinions from the attorney and give clear instruction to the Funds attorneys to reach settlement.
- Adhere to the time limits to prevent any wasted costs
- Attend to opinions from attorneys to ensure that the Fund is ready for trial when due.
- Report any risk to the senior to prevent any prejudice to the Fund.
- Arrange for interim disbursements to be attended to appropriately at Legal costs.
- Give proper instructions for settlement payments or payments in terms of court orders to prevent any unnecessary interest to be added.
- Arrange for the bill for costs to be referred to Legal costs to attend to and follow up on payment thereof.
- Report any actions from the Funds attorneys which is not in line with the Funds policies to the senior.
Compile Statistics
- Keep daily stats of activities on Undertakings and related matters.
- Submit daily stats and monthly stats as required by Management.
- Keep record of statistics.
Keep claims records
- Maintain record of all allocated matters.
- Maintain record of litigated matters.
- Maintain and apply a diary system used to pend matters to be followed up.
- Scrutinize incoming correspondence and maintain proper record thereof.
- Maintain proper record of files requested and returned to the I/S, referred to Medical and/or Administration cell.
- Keep record of private telephone calls and submit accurate telephone accounts on a monthly basis
Qualifications
- NQF 7 (Bachelor’s Degree OR Advanced Diploma) related qualification to discipline.
Experience
- Relevant 3 years’ experience in the claims environment
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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
Compliance administration
- Maintain up-to-date written documentation related to the departments 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
- Aid in the maintenance of correspondence, filing, telephonic queries and provide general administration support to the office.
- Maintain strict confidentiality in all matters relating to the office.
- Assist in making follow-ups on outstanding matters.
- Ensure all requests are handled and responded to within set timelines.
- Engage and follow up with Processing Centres on outstanding matters
- 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.
Meeting support
- Aid in arranging meetings on behalf of the department.
- Assist with taking and distributing minutes in accordance to set governance standards.
- Create and maintain a register to track matters outstanding.
- Support in the maintenance of follow-up plan on meeting resolutions and matters outstanding.
- Ensure confirmation of meetings and management of team diaries.
- Schedule appointments with internal and external stakeholders as and when required.
Document and Records Management
- Administer the records management and filing processes in line with the RAF filing plan.
- Ensure that the filing system is always up-todate and functional.
- Aid in the 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.
Qualifications
- Matric or Grade 12 certificate.
Experience
- Relevant 1 years’ experience in Administrative or similar environment.
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Key Performance Areas
Compliance administration
- Administer applicable standards, processes and procedures
- Maintain version control on documentation related to the departments 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
- Maintain strict confidentiality in all matters relating to the office.
- Make follow-ups on outstanding matters and escalate where required.
- Ensure all office requests are handled and responded to within set timelines.
- Ensure availability of stationery within the department.
- Compile and distribute relevant statistics and reports as per predefined standard as required.
- Coordinate operational office activities to ensure efficiency and compliance on the provision of the core function of the respective department.
Meeting support
- Provide support in setting up meetings.
- Take minutes and distribute these in accordance to set governance standards.
- Mantain follow-up plan on meeting resolutions and matters outstanding.
- Ensure confirmation of meetings and management of team diaries.
- Schedule appointments with internal and external stakeholders as and when required.
Financial and procurement processes administration
- Compile and follow up on requisitions with any procurement processes until finalised.
- Maintain the stock register for the department.
- Ensure timeous payment of invoices.
- Provide administrative support to all the departmental activities related to the SCM processes.
Document Control
- Ensure that the filing system is up-todate and functional.
- Manage the 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.
- Update and maintain assets register and inventory for the department.
- Maintain records of all files, correspondences and registers.
Qualifications
- National Diploma in Office Administration/Business Management/related or respective discipline qualification
Experience
- Relevant 2 years’ experience in an administrative or similar environment.
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Key Performance Areas
Policy Review and Implementation
- Contribute to the development and implementation of departmental policy, procedures and processes.
- Keep up to date with effective policy and practice execution strategies.
Preparation and Research on Related Litigation Matters
- Conduct research that will provide information in preparation for all matters for trial.
- Consult with client departments/ representatives, and witnesses for instructions and documentation for cases to be presented in Court.
- Draft pleadings to provide clear motivation/justification on a particular position about the case.
Mediation Process
- All required steps regarding the mediation process, as governed by the amendment to the rules of court, are to be taken.
- Upon conclusion of the mediation, parties shall inform Registrar and all other parties by a notice that Mediation is completed.
- Parties & Mediator must within 5 days of completion of mediation issue a joint minute indicating.
Represent the Road Accident Fund on all third party claims related litigation matters
- Attend court appearances in all allocated third-party litigation matters.
- Ensure file administration from opening to the conclusion of a legal case including adherence to trial dates.
- Handle appearances at courts, tribunals, mediation hearings and inquiries.
- Coordinate administrative legal actions to ensure compliance.
- Approve instructions to appoint and instruct expert witnesses.
Settle non-litigious matters before they are set down for trial
- Block consultation, early assessment of files, and early instructions to experts and assessors.
- Approve requests to appoint and instruct assessors and expert witnesses.
- Recommend a settlement.
Provision of legal advice to RAF
- Provide legal advice on arising legal matters and contracts.
- Provide well-researched legal advice on matters impacting the organisation.
- Conduct legal research and prepare legal opinions.
Taxation
- Deliver a full range of tax services in compliance with laws and regulations.
- Build relationships and interact with clients to provide consulting and expertise in tax services.
- Provide innovative tax planning and review complex income tax returns
Reporting
- Prepare and submit regulation reports as and when required to provide progress updates and/or inform management decisions.
- Develop reports/ policies/ procedures and guide the process through the alignment of the documents to the overall RAF’s Strategy.
- Develop functional reporting systems, for management, projects or performance reporting.
- Prepare proposals, briefings, presentations, reports, and other documentation and provide management information both verbally and in report format.
Stakeholder Management
- Facilitate and manage communication with relevant internal and external stakeholders in relation to investments and proactively and progressively manage the relationships.
- Manage relationships with vendors, service providers or procurement teams and ensure that all relevant procured items are invoiced and paid on time.
- Communicate with all levels of stakeholder contact.
People management
- Ensure the sourcing, development and retention of a high-performance team.
- Manage the recruitment of the operational workforce in line with employment equity targets.
- Manage staff in the department to ensure that they achieve their objectives in line with the strategic objectives of the RAF.
- Manage the implementation of human capital processes and procedures to control/regulate workplace conflict and/or institute corrective measures and consultation processes to address deviations from standards.
- Allocate, direct, motivate and evaluate subordinates to help them achieve their individual goals.
Qualifications
- Bachelor’s Degree in Law or equivalent.
- Postgraduate in Law or equivalent.
- Admission as an Attorney of the High Court or Advocate.
- Right of appearance in the High Court.
Experience
- Relevant 5-7 years legal experience post-graduation or admission of which 2 years must have been in area of expertise (personal injury litigation)
Method of Application
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