Medical Advisor

2 weeks ago

Pretoria, Gauteng, South Africa Stafflink Recruitment Solutions Full time

About the role:


Medical company has a key opportunity for a medical adviser, reporting to the Head: Operations, to contribute to the effective management of clinical risk and the cost-effective and appropriate utilisation of scheme benefits.


Qualifications and experience:

An MB Ch.
B.

degree and registered with the HPCSA, as well as at least 8 years relevant experience in the medical schemes industry.


Skills and knowledge:

  • Must possess a valid driving license.
  • Knowledge of the following:
Medical Schemes Act and Regulations.
Medical insurance industry.
Underwriting policies and procedures.
Non-declarations investigations; and
Clinical governance and knowledge.

Must possess the following skills:

Building positive working relations.

Leadership.

Innovative.

Financial and business insight;
Focused on the client

  • Responsible for benefit risk management through the following actions:
  • Evaluate and authorise procedures and out-of-hospital benefits.
  • Assist Case Management with the clinical justification of hospital benefits, including appropriate levels of care and/or alternatives to hospital admission.
  • Give input regarding the management of highcost cases; and
  • Provide clinical inputs on enquiries received from the Council for Medical Schemes.
  • Responsible for membership regulation through the following actions:
  • Provide inputs regarding underwriting for new members according to their clinical risk exposure.
  • Advise the Risk business unit on clinical risks associated with high claims and costs.
  • Assist with queries received from New Business, members, or advisers regarding preexisting medical conditions and whether underwriting should be applied according to the approved policy.
  • Evaluate and provide inputs on requests for benefit option interchanges from a clinical perspective.
  • Provide clinical advice when underwriting policies and guidelines are reviewed; and
  • Update underwriting policies in conjunction with the Innovation and Risk business units.
  • Assist with replies to the Council for Medical Schemes from a clinical perspective.
  • Provide input on the development of industrystandard guidelines.
  • Give feedback to Management on new clinical developments.
  • Stay abreast of changes in the clinical business landscape.
  • Manage and implement managed care initiatives.
  • Responsible for medical advisory services, including assisting with daytoday case management enquiries and routine medicine enquiries.
Participate in meetings requiring clinical input, such as high-cost meetings, clinical coding meetings, and out-of-protocol enquiries.

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