Medical Advisor

SUMMARY:
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POSITION INFO:

Together with our client in Pretoria, we are recruiting for a Medical Adviser. The ideal candidate must have at least 4 to 8 years of Medical Scheme experience and hold an MBChB/ MBBCh degree with active registration at the HPCSA.

Duties:

• Responsible for benefit-risk management through the following actions:
  • Investigate and recommend on the application of certain clinical item codes, in collaboration with the clinical coding specialist;
  • Evaluate and authorise procedures and out-of-hospital benefits;
  • Assist Case Management with the clinical justification of hospital benefits, including appropriate levels of care and/or alternatives to hospital admission;
  • Give input regarding the management of high-cost cases; and
  • Provide clinical inputs on enquiries received from the Council for Medical Schemes.
• Responsible for membership regulation through the following actions:
  • Provide inputs regarding underwriting for new members according to their clinical risk exposure;
  • Advise the Risk business unit on clinical risks associated with high claims and costs;
  • Assist with queries received from New Business, members or advisers regarding pre-existing medical conditions and whether underwriting should be applied according to the approved policy;
  • Evaluate and provide inputs on requests for benefit option interchanges from a clinical perspective;
  • Provide clinical advice when underwriting policies and guidelines are reviewed; and
  • Update underwriting policies in conjunction with the Innovation and Risk business units.
• Assist with replies to the Council for Medical Schemes from a clinical perspective.
• Provide input on the development of industry-standard guidelines.
• Give feedback to Management on new clinical developments.
• Stay abreast of changes in the clinical business landscape.
• Manage and implement managed care initiatives.
• Responsible for medical advisory services, including assisting with day-to-day case management enquiries and routine medicine enquiries.
• Participate in meetings requiring clinical input, such as high-cost meetings, clinical coding meetings, and out-of-protocol enquiries

Requirements:

• An MBChB/ MBBCh degree and registered with the HPCSA
• 4 to 8 years of relevant experience in the medical schemes industry
• Must possess a valid driving licence.
• Knowledge of the following:
  • Medical Schemes Act and Regulations;
  • Medical insurance industry;
  • Underwriting policies and procedures;
  • Non-declarations investigations; and
  • Clinical governance and knowledge.

• Must possess the following skills:
  • Building positive working relations;
  • Leadership;
  • Innovative;
  • Financial and business insight; and
  • Focused on the client.

Remuneration:

• 1 million to R1.3 million CTC per annum (this includes medical aid, pension & 13th cheque)

Closing date: 26 May 2023 @ 16H00

Only candidates who meet all the minimum requirements stipulated in the advert will be considered.

If you meet the above requirements, please submit your CV with supporting documents to with REF: MDMA – Pretoria

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NB! This job is now closed. You can apply for other jobs by uploading your CV.