Medical Advisor

4 weeks ago

Johannesburg, South Africa Specd Full time

**JOB DESCRIPTION**

***

**Job title**:Medical Advisor

**Location**:Randburg

**ROLE PURPOSE**:
To provide a medical advisory function within the Clinical Risk Division and Scheme to ensure the limiting of the Schemes exposure and to inform key strategic decisions.

**KEY AREAS OF RESPONSIBILITY**:
- Provide input into the development of the sub-divisions strategy.- Provide input into the tactical plan for the Clinical Risk sub-division to ensure execution of the strategic objectives and goals.- Drive the implementation of the tactical plan by developing and allocating operational activities and ensuring alignment to the achievement of operational targets.- Provide input into the establishment, maintenance and improvement of Standard Operating Procedures, policies, and guidelines relating to the Clinical Risk sub-division in consultation with the Executive: Clinical Risk.- Use insights gained through business information to compile reports, and metrics to measure success and inform the business decision making process and realign objectives.- Monitor and continuously evaluate progress of the sub-divisions achievements against the tactical plan and strategic objectives.- Provide clinical validation and advocacy to requests made by healthcare providers on behalf of Scheme members for high-cost procedures and medication.- Oversee the resolution of escalated queries received from the Operations division and third party managed care organisations to ensure effective feedback to members and in accordance with set Service Level Agreements (SLA).- Engage with medical professionals on escalated queries that require clinical decisions.- Prepare cases, presentation, and load member comments and clinical exceptions as required.- Arrange for second opinions and follow ups when required.- Identification new trends in industry and provide feedback to all stakeholders in order to inform business decisions.- Identify and target cost drivers in the Schemes healthcare expenses to reduce claim liabilities.- Provide input into high cost/high risk admissions being managed by third party organisations.- Provide input into the principles of healthcare funding and benefit design.- Record and maintain a database of clinical decisions.- Provide input into the evidence-based medicine principles, health economic principles and other managed care tools.- Provide feedback on areas of improvement of processes and system intelligence to enhance clinical rules and filters.- Continuously evaluate and monitor the financial performance of the Schemes claims loss ratio.- Ensure the effective communication of all clinical risk related decisions, costs improvements and shortfalls.- Provide input into the divisions risk register in consultation with the Manager: ARC.-
- Responsible for the coordination and maintenance of quality risk management in line with the requirements from ISO9001:2015.- Monitor changes in the regulatory environment and ensure that appropriate operational controls are implemented to address new requirements.- Support and provide evidence to all internal, external and ISO audit requirements.- Oversee the maintenance and enforcement of all clinical related Service Level Agreements to minimise business risk and ensure business continuity.- Ensure adherence in the Clinical Risk team to all relevant laws, policies and Standard Operating Procedures throughout the organisation.- Provide input in the planning and compilation of the divisions annual budget aligned to the tactical delivery plans to support the implementation of set objectives.- Ensure the effective implementation, management, monitoring of the divisions budget, and mitigate and report on any variances.- Ensure the deployment of proper financial controls to manage the budget.- Report on and communicate any operational costs improvements and shortfalls.- Build and maintain effective internal and external stakeholder relationships for the purpose of expectations management, knowledge sharing and integration.- Convene and attend meetings and present findings and business cases to relevant stakeholders when required.- Provide clinical guidance and advocacy to the business through involvement and support of clinical and non-clinical committees where appropriate.**COMPETENCY**:
**Experience**:

- 5 Years Medical Insurance environment
- 3 Years Health Care

**Education/ Qualification**:

- B-Degree in Medicine and/or Surgery (MB ChB)
- Health Professions Council of South Africa

**Knowledge**:

- Relevant legislation and regulatory frameworks
- Clinical Risk management
- Medical Knowledge
- Knowledge of the billing guides and modifiers
- Managed healthcare
- Claims assessing
- Prescribed Minimum Benefits (PMB)
- Financial budgeting and management processes
- Business Acumen

**Skills**:

- Verbal and Written Communication
- Conflict Resolutions
- Presentations
- Project Management
- Coaching and Mentoring

**Attributes**:

- Resilience
- Detail Orientation
- Innovative Thin

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