Medical Director: Clinical Governance

2 weeks ago

Pretoria, Gauteng, South Africa Growthlink Consulting Full time
Job Summary

We are seeking a highly experienced and skilled Senior Manager to lead our Medical Advisory Services team in Pretoria. The successful candidate will be responsible for executing clinical and medical advisory services within the Healthcare Management division, ensuring sound and compliant execution of clinical and medical advisory services.

Key Responsibilities
  • Assist the Chief Healthcare Officer in executing all clinical and medical advisory services within the Healthcare Management division.
  • Maintain clinical oversight on all aspects of the Schemes business.
  • 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.
  • Conduct systemic reviews of evidence-based clinical practice guidelines and ensuring that Scheme funding decisions are based on best practice.
  • Manage the activities of the Schemes Expert Advisory Panels that assist in maintaining the Scheme's evidence-based clinical protocols.
  • Timeously review and make funding decisions and/or recommendations on the Schemes Ex Gratia ratification cases using evidence-based medicine.
  • Manage and maintain the Schemes Ex Gratia guidelines.
  • Provide clinical expertise and support to the Schemes Ex Gratia Committee and Sub-Committee.
  • Oversee the Schemes Maternity Programme and ensure strategic objectives are achieved.
  • Oversee the Pathology & Radiology Benefits Management, including, but not limited to, claims management and clinical review of billing rules and tariff files.
  • Establish new alternative re-imbursement arrangements (ARMs) and value-based reimbursement arrangements in maternity, pathology, radiology, and high-cost medicines/biologics.
  • Review and ensure CMS circulars are responded to and timeously implemented.
  • Review and provide written responses on the clinical aspects of all CMS complaints, appeals, and all other complaints timeously.
  • Attend and participate in various Scheme Forums and make valuable contributions by providing the expertise needed to provide strategic and clinical advisory services.
  • Provide clinical expertise and support to the Schemes Divisions, as well as business units within the Healthcare Management division.
  • Represent the Scheme and actively participate in all external stakeholder forums, conferences, etc.
  • Support the Schemes strategic objectives and mandates. This includes elements of innovation that are key to the Schemes objectives.
Requirements
  • MBCHB as a minimum qualification. Must be registered with the Health Professions Council of South Africa (HPCSA).
  • Minimum 5 years of work experience in the medical aid/managed care industry.
  • Minimum 4 years as Manager / Senior Manager in the managed care/ medical aid industry.
  • Experience in Clinical and Financial Risk Management. Benefit Design Experience.
  • Must be in possession of a valid drivers license and own vehicle and be willing to travel at short notice.
  • A good understanding of all coding (Nappi, Tariffs, ICD10, CPT4, UPFS, and more).
  • The ability to conduct research using a variety of academic and market-related resources.
  • Essential skills:
    • Have a good understanding of the South African healthcare industry, the Medical Schemes Act, and other legislation;

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