Senior Manager Medical Advisor – Medical Scheme – Pretoria
Medical Advisor will report directly to the Chief Healthcare Officer and forms part of the Healthcare Management Division. The position is based in Head Office.
Key Performance Areas (KPAs):
Attend and participate at various Scheme Forums, and make valuable contributions by providing expertise needed to give strategic and clinical advisory services.
Provide clinical support within the Healthcare Management Division and the Scheme’s other divisions.
Maintain relationships with various stakeholders within the healthcare industry and stay abreast of new developments that impact the medical aid industry.
Provide oversight of the review of the Scheme’s funding policies, protocols and formularies.
Ensure that all risk areas applicable to the Healthcare Management Division are identified, communicated and strategies put in place to mitigate risk.
Manage the process for development and maintenance of Medical Advisory standard operating procedures and policies.
Drive Medical Advisory efficiency to deliver clinically approved and evidence based quality outcomes.
Direct all medical advisory activities to ensure successful attainment of strategic objectives.
Ensure an efficient and well-functioning medical advisory platform.
Contribute to targeted research into local and international clinical guidelines and funding policies.
Evaluate current cost drivers, trends and compare with those of local and international sources for best practice.
Manage the activities of the Scheme’s Expert Advisory Panels.
Critically analyse medical literature and use evidence-based principles to review and generate enhancements in funding protocols.
Review and provide expertise on new Health Technology assessments.
Develop and maintain adequate knowledge of data handling and interpretation of information translating interventions.
Perform tasks timeously, accurately and with necessary detail in response to issues raised.
Review and ensure all CMS circulars are responded to and timeously implemented.
Support Scheme’s ex gratia Committee and Sub-Committee.
Timeously review and make funding recommendations on the Scheme’s ex gratia ratification cases, using evidence based medicine.
Manage and maintain the Scheme’s Ex gratia guidelines
Review and provide written responses to all CMS complains and appeals timeously.
Assisting with all ad-hoc requests on any clinical and medical matters.
Participates on interdisciplinary committees within the Scheme.
Represent the Scheme and actively participate in DoH committees.
Support Scheme’s product development and benefit design activities.
Manage staff where necessary who are sub-ordinates.
Represent the Scheme at various stakeholder engagements.
Provide clinical support to the Scheme’s Disease Management Programmes.
Manage training, development and mentorship of staff.
Manage all the staff in the unit in accordance with the scheme’s HR Policy.
Qualification, skills and competencies requirements are:
MBCHB as a minimum qualification
Must be registered with the HPCSA.
Minimum 5 years work experience in the medical aid / managed care industry;
Minimum 4 years as Manager / Senior Manager in the managed care / medical aid industry
Experience in Clinical and Financial Risk Management.
Benefit Design Experience.