Senior Manager: Medical Advisory Services – Medical Scheme – Pretoria
3 months ago
KPAs
ü Assist the Chief Healthcare Officer in executing all clinical and medical advisory services within the Healthcare
Management division and maintain clinical oversight on all aspects of the Schemes business.
ü Ensure that the execution of clinical and medical advisory services within the Organisation are sound and in
compliance with the Medical Schemes Act and Regulations and the Scheme Rules.
ü Conduct systemic reviews of evidence-based clinical practice guidelines and ensuring that Scheme funding decisions are
based on best practice.
ü Manage the activities of the Schemes Expert Advisory Panels that assist in maintaining the Scheme's evidence-based
clinical protocols.
ü Timeously review and make funding decisions and/or recommendations on the Schemes Ex Gratia ratification cases
using evidence-based medicine.
ü Manage and maintain the Schemes Ex Gratia guidelines.
ü Provide clinical expertise and support to the Schemes Ex Gratia Committee and Sub-Committee.
ü Oversee the Schemes Maternity Programme and ensure strategic objectives are achieved.
ü Oversee the Pathology & Radiology Benefits Management, including, but not limited to, claims management and
clinical review of billing rules and tariff files.
ü Establish new alternative re-imbursement arrangements (ARMs) and value-based reimbursement arrangements in
maternity, pathology, radiology, and high-cost medicines/biologics.
ü Review and ensure CMS circulars are responded to and timeously implemented.
ü Review and provide written responses on the clinical aspects of all CMS complaints, appeals, and all other complaints timeously.
ü Attend and participate in various Scheme Forums and make valuable contributions by providing the expertise
needed to provide strategic and clinical advisory services.
ü Provide clinical expertise and support to the Schemes Divisions, as well as business units within the Healthcare
Management division.
ü Represent the Scheme and actively participate in all external stakeholder forums, conferences, etc.
ü Support the Schemes strategic objectives and mandates. This includes elements of innovation that are key to
the Schemes objectives.
REQUIREMENTS
ü MBCHB as a minimum qualification. Must be registered with the Health Professions Council of South Africa (HPCSA).
ü Minimum 5 years of work experience in the medical aid/managed care industry.
ü Minimum 4 years as Manager / Senior Manager in the managed care/ medical aid industry.
ü Experience in Clinical and Financial Risk Management. Benefit Design Experience.
ü Must be in possession of a valid drivers license and own vehicle and be willing to travel at short notice.
ü A good understanding of all coding (Nappi, Tariffs, ICD10, CPT4, UPFS, and more).
ü The ability to conduct research using a variety of academic and market-related resources.
ü Essential skills:
- Have a good understanding of the South African healthcare industry, the Medical Schemes Act, and
- other legislation;
-
Pretoria, South Africa Growthlink Consulting Full timeKPAsü Assist the Chief Healthcare Officer in executing all clinical and medical advisory services within the HealthcareManagement division and maintain clinical oversight on all aspects of the Schemes business.ü Ensure that the execution of clinical and medical advisory services within the Organisation are sound and incompliance with the Medical Schemes...
-
Medical Advisory Services Manager
5 days ago
Pretoria, Gauteng, South Africa Growthlink Consulting Full timeJob Title: Senior Manager: Medical Advisory Services – Medical Scheme – PretoriaAbout the Role:We are seeking a highly skilled and experienced Senior Manager to lead our Medical Advisory Services team. As a key member of our Healthcare Management division, you will be responsible for executing clinical and medical advisory services, maintaining clinical...
-
Medical Billing Debtors Clerk
3 months ago
Pretoria, South Africa Medical Debtors Services Full timeMedical Billing Bureau in Lynnwood Manor (Pretoria East) is excited to offer an employment opportunity to an experienced Medical Billing Administrator. Minimum requirements to apply: - Driver's license (ESSENTIAL). - Matric/Grade 12 qualification (ESSENTIAL). - 2 years Physiotherapy or Occupational Therapy billing experience (ESSENTIAL). - Computer skills...
-
Manager: External Stakeholder Support
1 month ago
Pretoria, South Africa Growthlink Consulting Full timeManager: External Stakeholder Support (Medical Doctor) Medical Scheme Pretoria KPAsü Manage the administrative function in the Medical Advisory Services business unitü Contribute to and conduct targeted research into local and international clinical guidelines andfunding policies.ü Critical review and analysis of current cost drivers and trends and...
-
Manager: External Stakeholder Support
1 month ago
Pretoria, South Africa Growthlink Consulting Full timeManager: External Stakeholder Support (Medical Doctor) Medical Scheme Pretoria KPAs ü Manage the administrative function in the Medical Advisory Services business unit ü Contribute to and conduct targeted research into local and international clinical guidelines and funding policies. ü Critical review and analysis of current cost drivers and...
-
Manager: External Stakeholder Support
1 month ago
Pretoria, South Africa Adzuna ZA B C2 Full timeManager: External Stakeholder Support (Medical Doctor) Medical Scheme Pretoria KPAsü Manage the administrative function in the Medical Advisory Services business unitü Contribute to and conduct targeted research into local and international clinical guidelines andfunding policies.ü Critical review and analysis of current cost drivers and trends and...
-
Medical Scheme Senior Operations Manager
3 months ago
Pretoria, South Africa Careforce Recruitment Full timeOur client, a managed care organisation in Pretoria are currently looking for a **Senior Manager: Operations. **Thisis an equal opportunity oganisation with various businesses and/ or subsidiaries that service clients in the medical scheme and insurance industries. **Reporting to**: Dual reporting role to both Chief Executive Officer and General...
-
Manager Clinical Stakeholder Support
1 month ago
Pretoria, South Africa Growthlink Consulting Full timeKey Performance Areas (KPAs): ü Manage the administrative function in the Medical Advisory Services business unit ü Contribute to and conduct targeted research into local and international clinical guidelines and funding policies. ü Critical review and analysis of current cost drivers, and trends and compare with those of local and international...
-
Manager Clinical Stakeholder Support
1 month ago
Pretoria, South Africa Adzuna ZA B C2 Full timeKey Performance Areas (KPAs): ü Manage the administrative function in the Medical Advisory Services business unitü Contribute to and conduct targeted research into local and international clinical guidelines and fundingpolicies.ü Critical review and analysis of current cost drivers, and trends and compare with those of local andinternational sources for...
-
Call Centre Agent
3 months ago
Pretoria, South Africa Careforce Medical Recruitment Full timeOur client, a managed care organisation based in Pretoria is looking for a Call Centre Agent. This is an equal opportunity organisation with various businesses and/ or subsidiaries that service clients in the medical scheme and insurance industries. Position: Medical Call Centre Agent - Adding or removing of dependants - Processing medical scheme membership...
-
Manager Clinical Stakeholder Support
1 month ago
Pretoria, South Africa Growthlink Consulting Full timeKey Performance Areas (KPAs): ü Manage the administrative function in the Medical Advisory Services business unitü Contribute to and conduct targeted research into local and international clinical guidelines and fundingpolicies.ü Critical review and analysis of current cost drivers, and trends and compare with those of local andinternational sources...
-
Medical Scheme Consultant
3 weeks ago
Pretoria, South Africa Adzuna ZA B C2 Full timeMy client, a leading and wellknown Medical Scheme Consultancy requires a competent and experienced Medical Scheme Consultant to be placed onsite on the campus of a reputable university in Pretoria.Requirements:Matric / Grade 12 Certificate ESSENTIALRE5 Qualification PreferredNQF 5 Qualification (relevant to Medical Scheme Industry) PreferredAt least 3 years...
-
Medical Scheme Consultant
4 weeks ago
Pretoria, South Africa Paqueta Personnel Full timeMy client, a leading and wellknown Medical Scheme Consultancy requires a competent and experienced Medical Scheme Consultant to be placed onsite on the campus of a reputable university in Pretoria.Requirements:Matric / Grade 12 Certificate ESSENTIALRE5 Qualification PreferredNQF 5 Qualification (relevant to Medical Scheme Industry) PreferredAt least 3...
-
Medical Scheme Consultant
2 weeks ago
Pretoria, Gauteng, South Africa Paqueta Personnel Full time**Job Title:** Medical Scheme Consultant**Job Summary:** Paqueta Personnel is seeking a highly skilled Medical Scheme Consultant to join our team. As a Medical Scheme Consultant, you will be responsible for interacting with clients in a professional manner, handling new applications and amendments, and providing expert advice on medical schemes.**Key...
-
Risk Analyst
3 months ago
Pretoria, South Africa Medpharm Recruitment Full timeA reputable Medical Aid Scheme is seeking an experienced Risk Analyst to join their team in Pretoria. A reputable Medical Aid Scheme based in Pretoria is in search of an experienced Risk Analyst to join their team. **Job Purpose**: - The position is responsible for promoting risk and regulatory compliance by identifying, quantifying, reviewing,...
-
Medical Credit Controller
4 months ago
Pretoria, South Africa Summit Medical Group Full timeBilling controller must have experience working with medical claims, ICD 10 and procedure codes. Must have GoodX experience. Person must have experience with IOD claims and Compeasy website. **Salary**: From R15,000.00 per month Ability to commute/relocate: - Pretoria, Gauteng: Reliably commute or planning to relocate before starting work...
-
Medical Advisor Manager
5 days ago
Pretoria, Gauteng, South Africa Growthlink Consulting Full timeJob Title: Medical Advisor ManagerGrowthlink Consulting is seeking a highly skilled Medical Advisor Manager to join our team. As a Medical Advisor Manager, you will be responsible for managing the administrative function in the Medical Advisory Services business unit.Key Responsibilities:Manage the administrative function in the Medical Advisory Services...
-
Medical Schemes Administrator
3 weeks ago
Pretoria, Gauteng, South Africa HR Options Full time**Job Summary**HR Options is seeking a highly skilled and experienced Medical Schemes Administrator to join our team. As a key member of our administrative staff, you will be responsible for providing exceptional client service and administrative support to our clients.**Key Responsibilities:****Client Interaction & Administration:**Regular interaction with...
-
Medical Advisor
4 months ago
Pretoria, 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...
-
Dur Pharmacist
3 months ago
Pretoria, South Africa Medpharm Recruitment Full timeA reputable Medical Aid is seeking an experienced DUR Pharmacist to join their team in Pretoria. **Duties**: - Medicine authorisations as per Scheme rules and protocols to ensure cost-effective reimbursement of medicine and medicine cost containment. - Ensure medicine benefit allocations are applied and executed correctly according to Scheme...