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.

DUTIES & RESPONSIBILITIES

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 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 adjudica...