Medical Advisor

2 weeks ago

Pretoria, South Africa Qetello Holdings Full time

**Duties**:

- 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

**Requirements**:

- An MBChB/ MBBCh degree and registered with the HPCSA
- 4 to 8 years of relevant experience in the medical schemes industry
- Must possess a valid driving licence.
- 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; and
- Focused on the client.

**Remuneration**:

- 1 million to R1.3 million CTC per annum (this includes medical aid, pension & 13th cheque)

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