Medical Advisor

**Job Advert Summary**:
Our client, a well-known and dynamic medical scheme, is currently looking for an experienced **Medical Advisor** for a **permanent opportunity** **in **Randburg** in** Johannesburg (Gauteng).**
- A Bachelor of Medicine and Bachelor of Surgery (MBBCh/MBChB) Degree
- At least 5 years' experience in the medical insurance environment in a similar role
- At least 3 years' experience in healthcare

**BENEFITS**:

- Medical Aid Contribution
- Pension Fund Contribution
- Annual bonus based on performance

**Minimum Requirements**:

- A Bachelor of Medicine and Bachelor of Surgery (MBBCh/MBChB) degree
- At least 5 years' experience in the medical insurance environment in a similar role
- At least 3 years' experience in healthcare
- Registered with the Health Professions Council of South Africa

**Knowledge**
- Relevant legislation and regulatory frameworks
- Clinical risk management
- Medical knowledge
- Knowledge of the billing guides and modifiers
- Managed healthcare
- Claims assessing
- Prescribed Minimum Benefits (PMB)
- Financial budgeting and management processes
- Business acumen

**Skills**
- Excellent verbal and written communication skills
- Strong conflict resolution skills
- Good Presentation and Project Management skills
- Coaching and Mentoring skills
- Sound Judgement and Decision-Making skills

**Attributes**
- Resilient and Assertive
- Detail Orientated
- Strategic and Innovative Thinking
- Client-Centric
- Results and Quality Focused
- Directing Others
- Problem Solving Orientated
- Analytical Thinking and Critical Reasoning

**Duties and Responsibilities**:
To provide a medical advisory function within the Clinical Risk Division and Scheme to ensure limiting the scheme’s exposure and to inform key strategic decisions.

**Key Areas of Responsibility**
- Provide input into the development of the sub-division’s strategy.
- Provide input into the tactical plan for the Clinical Risk sub-division to ensure execution of the strategic objectives and goals.
- Drive the implementation of the tactical plan by developing and allocating operational activities and ensuring alignment to the achievement of operational targets.
- Provide input into establishing, maintaining, and improving Standard Operating Procedures, policies, and guidelines relating to the Clinical Risk sub-division in consultation with the Executive: Clinical Risk.
- Use insights gained through business information to compile reports and metrics to measure success and inform the business decision-making process and realign objectives.
- Monitor and continuously evaluate the progress of the sub-division’s achievements against the tactical plan and strategic objectives.
- Provide clinical validation and advocacy to requests made by healthcare providers on behalf of scheme members for high-cost procedures and medication.
- Oversee the resolution of escalated queries received from the Operations division and third-party managed care organisations to ensure effective feedback to members and in accordance with set Service Level Agreements (SLA).
- Engage with medical professionals on escalated queries that require clinical decisions.
- Prepare cases, presentations, and load member comments and clinical exceptions as required.
- Arrange for second opinions and follow-ups when required.
- Identify new industry trends and provide feedback to all stakeholders to inform business decisions.
- Identify and target cost drivers in the scheme’s healthcare expenses to reduce claim liabilities.
- Provide input into high cost/high-risk admissions being managed by third-party organisations.
- Provide input into the principles of healthcare funding and benefit design.
- Record and maintain a database of clinical decisions.
- Provide input into the evidence-based medicine principles, health economic principles and other managed care tools.
- Provide feedback on areas of improvement of processes and system intelligence to enhance clinical rules and filters.
- Continuously evaluate and monitor the financial performance of the scheme’s claims loss ratio.
- Ensure the effective communication of all clinical risk-related decisions, cost improvements and shortfalls.
- Provide input into the division’s risk register in consultation with the Manager: ARC.
- Responsible for coordinating and maintaining quality risk management in line with the requirements from ISO9001:2015.
- Monitor regulatory environment changes and ensure appropriate operational controls are implemented to address new requirements.
- Support and provide evidence to all internal, external and ISO audit requirements.
- Oversee the maintenance and enforcement of all clinical-related Service Level Agreements to minimise business risk and ensure business continuity.
- Ensure adherence in the Clinical Risk team to all relevant laws, policies, and Standard Operating Procedures throughout the organisation.
- Provide input in the planning and compilation of the division’s an