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