Medical Advisor

2 weeks ago


Johannesburg, Gauteng, South Africa MHR Full time

Job Advert Summary:


Our client, a well-known and dynamic medical scheme, is urgently looking for an experienced
Medical Advisor for a
permanent opportunity
in Randburg
in Johannesburg (Gauteng).

**- A Bachelor of Medicine and Bachelor of Surgery (MBBCh/MBChB) Degree

  • At least 5 years' experience in the medical insurance environment in a similar role
  • Managed care/Managed healthcare experience is essential
  • At least 3 years' experience in healthcare

BENEFITS:

  • Medical Aid Contribution
  • Pension Fund Contribution
  • Annual bonus based on performance

Minimum Requirements:

  • A Bachelor of Medicine and Bachelor of Surgery (MBBCh/MBChB) degree
  • At least 5 years' experience in the medical insurance environment in a similar role
  • Managed care/Managed healthcare experience is essential
  • At least 3 years' experience in healthcare
  • Registered with the Health Professions Council of South Africa

Knowledge

  • Relevant legislation and regulatory frameworks
  • Clinical risk management
  • Medical knowledge
  • Knowledge of the billing guides and modifiers
  • Managed healthcare
  • Claims assessing
  • Prescribed Minimum Benefits (PMB)
  • Financial budgeting and management processes
  • Business acumen

Skills

  • Excellent verbal and written communication skills
  • Strong conflict resolution skills
  • Good Presentation and Project Management skills
  • Coaching and Mentoring skills
  • Sound Judgement and Decision-Making skills

Attributes

  • Resilient and Assertive
  • Detail Orientated
  • Strategic and Innovative Thinking
  • Client-Centric
  • Results and Quality Focused
  • Directing Others
  • Problem Solving Orientated
  • Analytical Thinking and Critical Reasoning

Duties and Responsibilities:


To provide a medical advisory function within the Clinical Risk Division and Scheme to ensure limiting the scheme's exposure and to inform key strategic decisions.


Key Areas of Responsibility

  • Provide input into the development of the subdivision's strategy.
  • Provide input into the tactical plan for the Clinical Risk subdivision to ensure execution of the strategic objectives and goals.
  • Drive the implementation of the tactical plan by developing and allocating operational activities and ensuring alignment to the achievement of operational targets.
  • Provide input into establishing, maintaining, and improving Standard Operating Procedures, policies, and guidelines relating to the Clinical Risk subdivision in consultation with the Executive: Clinical Risk.
  • Use insights gained through business information to compile reports and metrics to measure success and inform the business decisionmaking process and realign objectives.
  • Monitor and continuously evaluate the progress of the subdivision's achievements against the tactical plan and strategic objectives.
  • Provide clinical validation and advocacy to requests made by healthcare providers on behalf of scheme members for highcost procedures and medication.
  • Oversee the resolution of escalated queries received from the Operations division and thirdparty managed care organisations to ensure effective feedback to members and in accordance with set Service Level Agreements (SLA).
  • Engage with medical professionals on escalated queries that require clinical decisions.
  • Prepare cases, presentations, and load member comments and clinical exceptions as required.
  • Arrange for second opinions and followups when required.
  • Identify new industry trends and provide feedback to all stakeholders to inform business decisions.
  • Identify and target cost drivers in the scheme's healthcare expenses to reduce claim liabilities.
  • Provide input into high cost/highrisk admissions being managed by thirdparty organisations.
  • Provide input into the principles of healthcare funding and benefit design.
  • Record and maintain a database of clinical decisions.
  • Provide input into the evidencebased medicine principles, health economic principles and other managed care tools.
  • Provide feedback on areas of improvement of processes and system intelligence to enhance clinical rules and filters.
  • Continuously evaluate and monitor the financial performance of the scheme's claims loss ratio.
  • Ensure the effective communication of all clinical riskrelated decisions, cost improvements and shortfalls.
  • Provide input into the division's risk register in consultation with the Manager: ARC.
  • Responsible for coordinating and maintaining quality risk management in line with the requirements from ISO9001:201
  • Monitor regulatory environment changes and ensure appropriate operational controls are implemented to address new requirements.
  • Support and provide evidence to all internal, external and ISO audit requirements.
  • Oversee the maintenance and enforcement of all clinicalrelated Service Level Agreements to minimise business risk and ensure business continuity.
  • Ensure adherence in the Clinical Risk team to all relevant laws, policies, and Standard Opera

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