Medical Claims Review Officer (6 Months Fixed)
Contract Duration: 2024-11-22 - 2024-12-22
Location: Western Cape, CPT - CBD
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 to appropriate tariffs/ICD/CPT codes.
- Flagging rejected items/services.
- Recommendations to the 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.
- Reduce future healthcare costs and improve efficiencies by analysing trends in injured persons’ use of services.
- Compare outcomes and costs of different therapeutic modalities and surgical techniques.
- Manage future healthcare costs and improve efficiencies by analysing trends in utilization of services.
- Formal assessment of medical necessity and appropriateness of procedures to curb fraud and unreasonable demand for benefits.
Promote Good Working Relations with Stakeholders: - Check and advise on the tariffs used on accounts.
- Provide 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 departments of health services, government departments, and other key external stakeholders.
Check & Approve Payments in Terms of DOA: - Receive invoices and check payment requests 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.
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