Medical Advisor

4 weeks 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 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 high-cost 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 pre-existing 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 industry-standard 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 day-to-day 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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