Clinical Advisor

2 weeks ago

Johannesburg, Gauteng, South Africa 3Sixty Health (Pty) Ltd Full time

3Sixty Health has a great opportunity for a suitably qualified individual to fulfil the advertised position and join their team.

3Sixty Health is a black owned and managed, reputable and a major player in driving South

African economy by investing in ''black excellence''3Sixty Health is 100% black owned and black managed administrator as well as Managed Healthcare Organization.

It is accredited by the Council for Medical Schemes to offer both administration and managed care

3SIXTY HEALTH services, allowing for a fully integrated, beneficiary-centric approach. Our core

BACKGROUND
competencies in administration include membership management, billing, claim adjudication and customer services.

It is a medical aid administrator and Managed Healthcare of Sizwe Hosmed Medical
Scheme as well as SABMAS (South African Breweries Medical Aid Scheme)

POSITION CLINICAL ADVISOR

DIVISION MANAGED HEALTH CARE

DEPARTMENT OPERATIONS

LOCATION Head Office (Johannesburg)

To provide clinical leadership and advisory services. To represent the organisation in various provider relations areas.

Coordinates across all areas to ensure business objectives are met in order to drive overall provider engagement, satisfaction, and growth.

In this role, the Clinical

PURPOSE
Advisor seeks to align clinical solutions with clinical and business objectives, build relationships and credibility with key stakeholders effectively.

DUTIES AND RESPONSIBILITIES

  • Serve as the clinical expert providing technical support to the Managed health care department.
  • Contribute to the refining and adapting of Managed health care processes', policies and protocols. Policy development and supporting clinical research to be in line with the best practice in health management.
  • Meets or exceeds client needs by developing and delivering insightful, valueadded solutions that address complex client issues.
  • Devise and execute a plan to establish provider networks.
  • Peer to peer engagements where necessary
  • Present and demonstrate to customers and prospects the value proposition and ROI of assigned solutions in a consultative approach via WebEx and in person as appropriate.
  • Create and execute upon an annual business plan that aligns with achieving monthly, quarterly, and annual quota and goals.
  • Ensures managed care contracts include required contract language for different payment models to include risk, maximize revenue and minimize risk and address impacts to utilization management, claims processing, and contract performance monitoring.
  • Support in the development of Alternative Reimbursement Models
  • Support in Clinical Risk Management interventions
  • Provide clinical validation to requests made by healthcare providers on behalf of our members for highcost procedures and medication.
  • Provide clinical leadership and guidance to the business through involvement and support of clinical and non
- clinical committees.

  • Areas of clinical advisory including HIV Management, Oncology, Drugs and Care Schedule, Radiology including specialized radiology, Pathology, Acute conditions, chronic conditions, Pharmacology, Inhospital Cases and other Disease Management Programmes. The aim of the is to advise on clinical standards and practices in order to strengthening an integrated service model for stakeholder.
  • Support the operational areas in clinical data analysis and input to the operational reports.
  • CMS, exgratia research, support and compilation of cases
  • Support in Clinical Training of staff in areas identified clinical as challenges.
  • Provide Benefit Design inputs.
  • Support in Tariff negotiations with Providers
  • Review of clinical mandates such as Exgratia etc.
  • Providing support with establishment of PPP (Private Public Partnerships)
  • Ensuring that the organization and its clients are up to date with industry developments.

Liaison

  • Business unit clinical representation in different stakeholder relationships with; the Medical Scheme Client,
Specialist doctor Organisations, Provider Networks, Hospital Groups, Pharmaceutical companies, CMS, BHF etc.

  • Promote compliance with department and organizational objectives.
  • Represent the business in Clinical Governance Committees, tariff negotiations with hospital groups and provide feedback to management on businesstobusiness relationships.
  • Representing the company in negotiations with suppliers of medical equipment, pharmaceutical companies, rehabilitation centres etc.

Quality Assurance

  • Provide feedback and improvement on processes and system intelligence in other departments within the business unit and advice on clinical rules and filters.
  • Work in conjunction with the clinical coder, and the IT department on system optimisation for the managed care area.

QUALIFICATIONS AND EXPERIENCE

  • MBChB, experience in managed healthcare environment preferable
  • Business Administration/Management post graduate qualification would be an advant

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