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;
