Professional Nurse Grade 1-3: Medical Adjudication

Requirements

Four (4) years’ degree (NQF7)/ three (3) years’ Diploma in Nursing (NQF6). Post Graduate Diploma (NQF8) in Occupational Health / Theatre Technique / Critical Care will be an advantage. Grade 1: 2-9 Years’ experience gained after registration, Grade 2: 10-19 Years’ experience gained after registration. Grade 3: 20 Year’s and above experience gained after registration. Experience in trauma/emergency/internal medicine/general surgery/orthopaedics/theatre at the regional public hospital level or private hospital. Experience in medical claims processing/insurance environment will be an added advantage. Registration with the South African Nursing Council. Knowledge: Medical related Legislation, Medicines and related Substances Act, Medical aid knowledge (case management), Occupation Health knowledge, Regulatory Knowledge & Implementation, Del and Compensation Fund objectives and business functions, Nursing legislations and related legal as well ethical nursing practices, Compensation Fund policies, procedures and processes, Stakeholders and customers, Customer Service (Batho Pele Principles), Fund Values, Occupational Health and Safety Act (OHS), COIDA Act, Regulations and Policies, COIDA tariffs, Technical Knowledge, PFMA and National Treasury Regulations, General knowledge of the Public Service Regulations, Public Service Act, Health Professions Act, Health Act. Skills: Post claims management and settlement, Claims handling, Claims settlement management, Medical Policy Management, Clinical Excellence and Advisory, Project Management and Planning, Information Analysis and Interpretation, Digital Acumen/Medical Systems (IT Systems Control Designs), Clinical Coding, Quality Assurance and Improvement, Research and Benchmarking.

Key Responsibilities

Provide advice and recommendation in the acceptance of liability. Recommend the approval for medical accounts. Provide medical advice on the processing of occupational injury claims. Determine PD (Permanent Disability) and TTD (Total Temporary Disability). Assess medical accounts on occupational injury claims and OD medical accounts.

How to Apply

Enquiries

Notes

Priority will be given to Coloured Male, Coloured Female, Indian Female, White Male, White Female