Description:
PLEASE NOTE THAT NO CV WILL BE KEPT FOR FUTURE USE. IF YOU DO NOT GET FEEDBACK WITHIN 3 WEEKS PLEASE SEE YOUR APPLICATIONS AS UNSUCCESSFULA COVERING LETTER MUST BE ADDED TO APPLICATION WITH THE VALUE THAT YOU CAN ADD AND WHY YOU ARE APPLYING.
MBChB.
Valid registration with HPCSA.
Additional post graduate certifications.
The successful candidate will be responsible for but not limited to the following functions: ·
Provide clinical support to the Clinical Committee, Executives and Schemes 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.
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
04 Jul 2025;
from:
gumtree.co.za