Job Description

A managed healthcare company is seeking a Medical Advisor.
Medical Advisory services are an intrinsic requirement to guide and support the accredited managed healthcare services so that services are rendered in compliance with the Medical Schemes Act, various CMS scripts and/ or publications, prevailing legislation, scheme rules, funding guidelines, treatment protocols and payment structures.
Key Purpose of the Position:
The position requires the successful candidate to be able to make sound funding decisions for clinically complex cases in accordance with scheme rules, funding guidelines, treatment and managed care protocols. The successful candidate needs to uphold the principles of evidence and outcome-based medicine, promote cost effective and quality care for members as well as manage mutually beneficial interactions and effective and concise communication with both external and internal healthcare providers and other stakeholders.
Qualifications and Experience:

• MBChB
• Valid registration with HPCSA
• Additional post graduate certifications advantageous

Key Responsibilities:

• The successful candidate will be responsible for but not limited to the following functions:
• Provide clinical support to the Clinical Committee, Executives and Scheme's management with escalations and/ or complaints as well as the various clinical teams in pre-authorisation, hospital case management, clinical audit, active disease and chronic risk management, oncology case management, pharmaceutical benefit management and spinal programme management.
• Ensuring the medical advisory workflows are attended to and the turn-around times are met.
• Review of clinical evidence on a case-by-case basis.
• Daily Clinical Review which includes the preparation of cases and case presentation of clinical exceptions and/or high cost/ high risk cases, the arranging of second opinions and follow-up.
• Succinct communication of funding decisions to the relevant parties (healthcare provider, member, broker and other stakeholders) telephonically and in writing.
• Actively participating in key clinical forums/ committees both internally and externally.
• Supporting clinical staff and other Medical Advisors.
• Building and maintaining mutually beneficial relationships with external health care providers.
• Knowledge of various healthcare industry coding and claims structures and assisting to achieve payment resolutions.
• Identify and communicate operational challenges that are impacting the delivery of the managed healthcare services and participate in improvement strategies.
• Staying up to date with legislative and industry changes and how it may affect the various managed care services
• Identification of new trends in the medical industry, and engagement with relevant clinical and funding stakeholders pertaining to the potential impact thereof.
• Keeping updated with the latest clinical trends, new medical technologies and attending CPD events.
• Liaise with various business units within the greater Rx Group and share clinical guidance when needed.

Knowledge and Skills:

• Experience within Medical Scheme and/ or managed healthcare environment (3 - 5 years)
• Knowledgeable of the Medical Schemes Act, PMB legislation and various Council for Medical Scheme Scripts and Publications.
• In-depth knowledge and understanding of all industry coding and fee structures - ICD10, CPT, RPL, SAMA Billing Guide, global fees, per diem, etc.
• Practical clinical experience in a private hospital or clinic performing and/ or assisting with surgical procedures.
• Experience in protocol, funding guideline and treatment basket development and implementation.
• Health economics understanding.
• In-depth knowledge of health metrics reporting for e.g. health outcomes, value-based care etc. and the application thereof to develop appropriate/ needed health programmes and treatment baskets to address health and funding risks
• Ability to present and clearly communicate clinical information and funding decisions in a constructive manner to healthcare providers, both internally and externally.
• Excellent written and verbal communication skills in English
• Computer literacy in Microsoft Office applications as a minimum, experience in using any healthcare systems applications will be advantageous.

Competencies:

• Accountable
• Action and results orientated
• Communicates clearly and effectively
• Collaborates and supports open engagement
• Manages and resolves conflicts
• Customer (healthcare provider, member and other stakeholder) focused
• Demonstrates business and operational insight
• Supports a culture of continuous learning and development
• Adaptable
• Values and respects differences
• Embrace technology and new healthcare innovations

Candidates that meet the criteria may submit their applications via this portal or via vacancy link on www.mnarecruitment.com
Should you receive no feedback within 7 days, please accept your application as unsuccessful