The Road Accident Fund (RAF) is a South African state insurer that provides compulsory cover to all road users against personal injury or death from motor vehicle accidents within the country’s borders. The fund is financed through a levy on motor vehicle fuel.

Purpose of the Job: The Consultant: Medical Management is responsible to implement the medical management activities, medical exception handling and providing administration support in claims processing.

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.
• Pre-authorise 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 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 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.
• Relevant 3 years’ experience in A Medical related environment.

Technical Competencies Required

• Claims management process/processes and systems.
• Medical product management.
• Medical bill reviewing
• Medical case management

Behavioural Competencies Required

• Planning, Organising and Coordinating
• Personal mastery
• Judgment and decision making
•  Ethics and Values
• Client Service Orientation