Senior Medical Advisor

2 weeks ago

Sandton, South Africa Discovery Ltd. Full time

Business Unit:
Discovery Health
Function:Clinical
Date:9 May 2024- Discovery Care
Senior Medical Advisor - Gauteng

About Discovery

  • Discovery's core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fastpaced and dynamic environment enables smart, selfdriven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.
    About Discovery Care


Discovery Care is a subsidiary for Discovery Health - made up of 8 distinct areas with segmented teams responsible for the processing of specialized claims, CIB queries and escalated clinical queries processes while our case management teams are responsible for reviewing clinical cases for each of the specialized areas.

Our clinical services area is also responsible for all council disputes while our high touch team provide hands on services and escalated query resolution to sensitive cases.


Key Purpose:

  • The incumbent's role is to be the central clinical support within the Benefit Compliance Review (BCR) team including Council for Medical Schemes complaints and disputes, as well as the Ex Gratia team.

Key
Purpose:

The successful applicant will be responsible for but not limited to the following job functions:

  • Provides clinical support in preparing and presenting all disputes (rule 27) and compiling of responses to the Council for Medical Schemes, including vetting of letters in order to ensure quality of output and service delivery.
  • Source all the relevant clinical evidence pertinent to each case and obtain input from relevant external experts proactively when required.
  • Liaise with the treating doctor and other relevant medical providers.
  • Develop sound working relationships with CCE, Risk and other relevant internal stakeholders and involve these areas in member specific decisions; use these inputs to inform and enhance processes and benefits.
  • Provide clinical upskilling to all BCR colleagues on identified clinical topics.
  • Assist Clinical and nonclinical staff with guidance and input where required.
  • Provide feedback on Ex-Gratia Cases at the Clinical Governance Forum.
  • Support the Legal Advisors with the Biweekly Dispute Committee meeting and to provide all relevant clinical information related to the case.
  • Guide the Legal Advisors when preparing Heads of Argument for the Council of Medical Schemes
  • Deal with complaint escalations by doing a thorough investigation of the case and providing recommendations to the Schemes by writing a formal response on behalf of the Administrator.
  • Build and maintain effective working relationships with internal and external stakeholders such as the Council for Medical Schemes, DHMS as well as all in house schemes administered by Discovery Health, their Fund Managers and Principal Officers.
  • Play an integral role in various internal steer committees such as Prescribed Minimum Benefits, Underwriting, Health Partners, and Forensics in order to make the necessary improvements and proactively avoid complaints or disputes.
  • In conjunction with the CCE unit, develop guiding principles based on the rulings made by the Council for Medical Schemes and communicate these to all relevant stakeholders.
  • Participate in business continuous improvement initiatives arising from Disputes and CoMS complaints e.g. at PMB forum.
  • Attend In House Ex-Gratia committee meetings as required to provide relevant clinical input.

Competencies:

**Role Specific Behaviours

  • Ensures accountability.
  • Action oriented
  • Manages ambiguity.
  • Attracts top talent.
  • Business insight
  • Collaborates
  • Communicates effectively.
  • Manages complexity.
  • Manages conflict.
  • Courage
  • Customer focus
  • Decision quality
  • Develops talent
  • Values differences
  • Directs work.
  • Drives engagement
  • Financial acumen
  • Global perspective
  • Cultivates innovation.
  • Interpersonal savvy
  • Builds networks.
  • Nimble learning
  • Organizational savvy
  • Persuades
  • Plans and aligns.
  • Being resilient
  • Resourcefulness
  • Drives results
  • Demonstrates selfawareness.
  • Selfdevelopment
  • Situational adaptability
  • Balances stakeholders
  • Strategic mindset
  • Builds effective teams.
  • Tech savvy
  • Instils trust.
  • Drives vision and purpose
  • Optimizes work processes

Education and Experience:

The following requirements are essential:

  • Matric
  • MBBCH
  • Registered with the relevant professional body
  • At least 2 years clinical experience, post community service
  • 23 years of managed healthcare experience

The following requirements will be advantageous:

  • Health Economics and or law related qualification and/or experience

Personal Attributes or Competency Profile

The Discovery Person

  • Values Drive

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