We are recruiting for a Medical Claims Review Officer position.
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 company guidelines and the company 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 they will be in effective in curbing fraud and over servicing unreasonable demand of benefits from victims.
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.
Preauthorisation 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.
