OFFICER: BILL REVIEW
Location: Pretoria
Salary: R434 656.00 per annum
Purpose of the Job
Review of Medical Bills
Duties & Responsibilities
Audit and 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 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 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 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
effective in curbing fraud and over servicing unreasonable demand of benefits from victims of
road accidents.
Promote good working relations with Stakeholders.
•Check and advise on 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.
Technical and behavioral competencies required
• Computer literacy.
• Ability to interpret the rules of the UPFS tariffs.
• Analytical skills.
• Organisational and administrative skills.
• Planning and Organisation.
• Decision making.
• Negotiation skills.
• Personal mastery.
• Emotional wisdom.
• Ethics and governance.
• Customer orientation and customer focus.
Desired Experience & Qualification
• NQF6 (Diploma or Advanced Certificate) in Nursing or Allied Health Professions or related qualification to discipline.
• NQF 7 (Bachelor’s Degree or Advanced Diploma) in Nursing or Allied Health Professions related qualification to discipline will be an added advantage.
• Registration with the relevant Health Professions Council.
• Relevant 3 years’ experience in a medical field.
Package & Remuneration
R434 656.00 per annum, negotiable
Additional information
NB:
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.
All the best with your applications
