Strategic Medical Services Director
11 hours ago
We are seeking an experienced and skilled Strategic Medical Services Director to join our team at Growthlink Consulting in Pretoria. This is a fantastic opportunity for a medical professional to utilize their expertise in clinical and financial risk management, benefit design, and more.
Responsibilities- Assist the Chief Healthcare Officer in executing all clinical and medical advisory services within the Healthcare Management division and 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.
- Must hold MBCHB as a minimum qualification and 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.
R1,200,000 - R1,500,000 per annum, depending on experience.
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