Medical Management & Claims Consultant

Our client is recruiting for a Consultant: Medical Management who will be responsible for implementing the medical management activities, medical exception handling and providing administrative support in claims processing.

• 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 organization and / or any that is considered reasonable.
• Pre authorise submitted claims aligned to the organization's clinical guidelines including the 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.

• Ensure the implementation and maintenance of a formal exceptionhandling process within the medical management.
• Maintain the documentation and regular updating of the exception handling process.
• Maintain the implementation an unusual occurrence procedures.

• 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.

• 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.

• Bachelor's Degree/Advanced Diploma in Health Sciences /Medical related qualification.
• Registration with HPCSA/SANCA.

• Relevant 3 years' experience in a Medical related environment.