Specialist: Ambulatory Benefits Management

2 weeks ago

Pretoria, South Africa Source and Select Full time

**Are you ready to accelerate your career?**

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GEMS is currently seeking a highly skilled **Specialist in Ambulatory Benefits Management** to join their esteemed Healthcare Management team. This position is based at their Head Office and will report directly to the Manager of Ambulatory Benefits Management

**To be considered for this position, the following qualifications and experience are required**:

- Minimum of a 3-year Degree, Diploma or NQF Level 6 in Medical/Clinical Sciences Qualification (Nursing qualification advantageous)
- _ At least 4-6 years work experience in the Healthcare funding/Medical Schemes industry_
- Solid Hospital Benefits and Disease Risk Management Operations experience with Medical Scheme operational insight

**Here's an overview of the responsibilities you'll have in this role**:

- Collaborating with and providing support to the Manager: Ambulatory Benefits in effectively managing all aspects of out-of-hospital benefits for the Scheme.
- Assisting in the development and implementation of GEMS Clinical Risk Management Platform, aligning with the Scheme's strategic objectives and mandates. This includes managing access to out-of-hospital benefits and utilisation management.
- Supporting the Manager in overseeing various managed care processes, such as aPMB (Prescribed Minimum Benefits) authorisation, PMB query management (prospective and retrospective), Disease Management Programs (DMPs), Value-Based Care programs, and inter-SPN (Service Provider Network) integration processes. Additionally, contributing to other projects aligned with the Scheme's strategy.
- Participating in relevant forums and providing input to enhance strategic clinical and utilisation risk management.
- Facilitating the timely and accurate rollout of defined programs.
- Assisting in the development and implementation of a quality assurance and utilisation review program specifically tailored to GEMS' ambulatory benefits.
- Supporting the development, evaluation, and revision of Standard Operating Procedures (SOPs) related to out-of-hospital benefits and clinical risk management. Responding to raised issues promptly, accurately, and with attention to detail.
- Must be in possession of a valid driver’s license and be willing to travel at short notice.

**You will be a perfect fit for the role if you have the following**:

- Strong analytical skills and ability to effectively manage priorities. - Excellent written and verbal communication skills, along with exceptional interpersonal abilities. - Demonstrated critical thinking skills. - Capability to work both independently under pressure and collaboratively as part of a team. - A team player with strong organizational skills. - Adaptability and resilience in a dynamic work environment. - Knowledge of Project Management would be an added advantage. - Proficiency in using the MS Office Suite. - Well-organised with good time management skills. - Adaptable and resilient nature. - Self-motivated and proactive, with a strong initiative.
- Updated resume/CV
- Cover letter (optional but recommended) - briefly introduce yourself and express your interest in the position
- Any relevant certifications or supporting documents
- Attach your resume/CV, cover letter, and any additional documents you wish to include.

**Additional Information**:

- GEMS places a strong emphasis on hiring individuals with the utmost integrity. Therefore, submission to the appropriate pre-employment assessment is mandatory for consideration for this position.
- GEMS follows a hybrid work model, allowing for a flexible combination of remote and on-site work.
- GEMS is guided by the principles of employment equity, and preference will be given to underrepresented groups in accordance with GEMS' employment equity plan.

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