Specialist: Ambulatory Benefits Management

2 weeks ago


Pretoria, Gauteng, South Africa Source and Select Full time

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GEMS is currently seeking a highly skilled
Specialist in Ambulatory Benefits Management to join their esteemed Healthcare Management team. This position is based at their Head Office and will report directly to the Manager of Ambulatory Benefits Management

To be considered for this position, the following qualifications and experience are required:

  • Minimum of a 3-year Degree, Diploma or NQF Level 6 in Medical/Clinical Sciences Qualification (Nursing qualification advantageous)
- _ At least 4-6 years work experience in the Healthcare funding/Medical Schemes industry_

  • Solid Hospital Benefits and Disease Risk Management Operations experience with Medical Scheme operational insight

Here's an overview of the responsibilities you'll have in this role:

  • Collaborating with and providing support to the Manager: Ambulatory Benefits in effectively managing all aspects of out-of-hospital benefits for the Scheme.
  • Assisting in the development and implementation of GEMS Clinical Risk Management Platform, aligning with the Scheme's strategic objectives and mandates. This includes managing access to outofhospital benefits and utilisation management.
  • Supporting the Manager in overseeing various managed care processes, such as aPMB (Prescribed Minimum Benefits) authorisation, PMB query management (prospective and retrospective), Disease Management Programs (DMPs), Value-Based Care programs, and interSPN (Service Provider Network) integration processes. Additionally, contributing to other projects aligned with the Scheme's strategy.
  • Participating in relevant forums and providing input to enhance strategic clinical and utilisation risk management.
  • Facilitating the timely and accurate rollout of defined programs.
  • Assisting in the development and implementation of a quality assurance and utilisation review program specifically tailored to GEMS' ambulatory benefits.
  • Supporting the development, evaluation, and revision of Standard Operating Procedures (SOPs) related to outofhospital benefits and clinical risk management. Responding to raised issues promptly, accurately, and with attention to detail.
  • Must be in possession of a valid driver's license and be willing to travel at short notice.

You will be a perfect fit for the role if you have the following:

  • Strong analytical skills and ability to effectively manage priorities.
  • Excellent written and verbal communication skills, along with exceptional interpersonal abilities.
  • Demonstrated critical thinking skills.
  • Capability to work both independently under pressure and collaboratively as part of a team.
  • A team player with strong organizational skills.
  • Adaptability and resilience in a dynamic work environment.
  • Knowledge of Project Management would be an added advantage.
  • Proficiency in using the MS Office Suite.
  • Well-organised with good time management skills.
  • Adaptable and resilient nature.
  • Self-motivated and proactive, with a strong initiative.
  • Updated resume/CV
  • Cover letter (optional but recommended) briefly introduce yourself and express your interest in the position
  • Any relevant certifications or supporting documents
  • Attach your resume/CV, cover letter, and any additional documents you wish to include.

Additional Information:

  • GEMS places a strong emphasis on hiring individuals with the utmost integrity. Therefore, submission to the appropriate preemployment assessment is mandatory for consideration for this position.
  • GEMS follows a hybrid work model, allowing for a flexible combination of remote and onsite work.
  • GEMS is guided by the principles of employment equity, and preference will be given to underrepresented groups in accordance with GEMS' employment equity plan.


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