Job Description

Job Advert Summary

An exciting opportunity for a Medical Advisor exists in the High Cost and Policy Development group. The successful candidate will provide medical expertise on patient management when reviewing hospital admissions, taking Scheme rules and legislation into account and to provide a client focussed cost effective service.

Minimum Requirements

Must be a Medical Doctor registered with Health Professions Council of South Africa (HPCSA). Medical indemnity insurance will be an added advantage. Must have sound knowledge of the Medical Aid Industry, Rules & Regulations, and other related legislation. Sound knowledge of PMB guidelines and Industry knowledge would be an added advantage. Excellent business writing & communication skills with exceptional telephone etiquette. Must have strong organisational awareness in order to anticipate the impact of actions on other groups. Time Management & good administration skills. Effective conflict resolution skills and the ability to work under pressure. Must be a strong team player and results driven. Computer literacy (MS Office).

Duties and Responsibilities

Advise the Managed Healthcare (MHC) group on clinical matters pertaining to, pre-authorization, case management, benefit management e.g. PMBxe2x80x99s, disease management and pharmaceutical benefit management, non disclosures etc. in order to ensure clinical appropriateness of benefits. Recommend various internal groups and the Scheme on clinical matters to ensure that the rules of the Scheme has been correctly applied and implemented. Assess individual cases in accordance with that diagnoses and clinical data motivation letter/benefit structure/Rules of the Scheme/clinical knowledge/experience to facilitate clinical appropriateness of benefits. Assist with the development, implementation and maintenance of Clinical protocols and internal processes for the MHC group to ensure consistency in the application of benefits. Facilitate and provide clinical training to the MHC group to ensure the continuous updating of clinical knowledge and skills, as well as medical advancements. Amend appropriate training material as required to ensure the most up to date clinical information is available. Attend meetings, interdepartmental forums, benefit design workshops, third party representatives and the Scheme to provide clinical input and expertise where it may be required. Attend the Medical Advisory Group meetings/ conferences for the adoption of clinical policies and to keep abreast of industry trends, developments and norms. Research scientific clinical data in order to source advancements to keep abreast of industry trends, developments and norms and advise the Scheme on benefit design and reimbursements. Consult with medical specialists and professional bodies to obtain their expert opinions. Recommend alternative treatment plans using physicianxe2x80x99s motivation letter/Benefit structure/Rules of the Scheme to ensure the most cost-effective treatment. Liaise with service providers to exchange information and discuss referred cases. Refer appeals to the Clinical Committee for a final decision and compile the official reply to the complainant in order to adjudicate the Clinical Committee's decision. Review and respond to clinical queries from CMS. Oversee the high cost strategy for the schemes, deal with alternate drug reimbursement models and oversee the policy management.