Division: Claims
Reference No: 3904
Location:
Cape Town, Western Cape, ZA
Employment Type: Fixed Term Contract
Disability (EE targeted role): Yes
T.A.S.K Grade: 10
Job Posting Salary: R434,656.00
Job Posting End Date: 10 Sep 2024
The Road Accident Fund’s mission is to provide appropriate cover to all road users within the borders of South Africa; to rehabilitate and compensate persons injured as a result of motor vehicle accidents in a timely and caring manner; and to actively promote safe use of our roads.
Note: This is a 6 Months Fixed Term Contract
Purpose of the Job: Review Medical Bills.
Key Performance Areas
Audit & review medical bills.
- Analysis of claimed items/services in correlation with available tariff structures and ICD 10 /CPT 4 codes.
- Requesting motivation for unreasonable accounts.
- Line by line analysis of claim items/service. Matching those appropriate tariffs/ICD/CPT codes.
- Flagging rejected items/services.
- Recommendations to department responsible for processing payments.
- Auditing medical claims and assisting in technical aspects of bill review.
- 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 to curb over servicing or abuse and fraudulent claims.
- Ensuring that the accounts are paid timeously according to the service level agreements.
- Ensure that the services and treatments claimed are accident related/ (related to the accident under consideration).
- Reduce future healthcare cost and improve efficiencies by analysing trends in in injured person’s use of services.
- Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided.
- Manage future healthcare costs and improve efficiencies by analysing trends in utilization of services.
- Formal assessment of medical necessity and appropriateness of procedures the will be in effective in curbing fraud and over servicing unreasonable demand of benefits from victims of road accidents.
Promote good working relations with Stake Holders.
- Check and advise on the tariffs used on accounts.
- Provided training on new developments.
Approve medical expenses in accordance with relevant DOA.
- Authorisation in accordance with mandate.
- Inform service provider of payment decision.
Assisting in technical aspects of bill review.
- Develop and manage relationships with department of health services, government dept and other key external stake holders.
Check & approve Payments in terms of DOA.
- Receive invoices and check payment request for accuracy and correctness.
Determine the level of care based on functional ability.
- Analysis of medical data available e.g. Case Manager’s Reports, Clinical Records and Medico – Legal Reports.
Pre authorisation of procedures.
- Analyse medical data to determine the need for the service.
- Timeous assessment of urgent files e.g. Road Shows.
Qualifications
- Bachelor’s Degree or Advanced Diploma in nursing/ Allied Health Professions or related qualification
- Registration with the relevant Health professions council.
Experience
- Relevant 3 years’ experience in a medical field.
Competencies
Behavioural:
- Personal mastery
- Emotional Wisdom.
- Ethics and Governance.
- Customer orientation and customer focus.
Technical:
- Computer literacy.
- Ability to interpret the rules of the UPFS tariffs.
- Analytical skills.
- Organisational & Administrative skills
- Planning and Organising
- Decision making
- Negotiation skills.
NB: “RAF offers Total Employment Cost packages with no additional contributions from the Employer, successful candidates are required to structure their packages in a manner that will suit their needs”
The Road Accident Fund subscribes to the principles of employment equity and preference will be given to People with Disabilities.
Applicants who have not received any correspondence from us within six weeks from the closing date can consider themselves unsuccessful
Security Vetting shall be conducted on all prospective employees
It is the applicants’ responsibility to have foreign qualification evaluated by the South African Qualification Authority (SAQA) and to provide proof of such evaluation.
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