Senior Manager: Medical Advisory Services – Medical Scheme – Pretoria

SUMMARY:
Senior Manager: Medical Advisory Services – Medical Scheme – Pretoria

POSITION INFO:

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 Scheme’s 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 Scheme’s 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 Scheme’s Ex Gratia ratification cases

using evidence-based medicine.

ü Manage and maintain the Scheme’s Ex Gratia guidelines.

ü Provide clinical expertise and support to the Scheme’s Ex Gratia Committee and Sub-Committee.

ü Oversee the Scheme’s 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 Scheme’s 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 Scheme’s strategic objectives and mandates. This includes elements of innovation that are key to

the Scheme’s 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 driver’s 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;

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