Clinical Appeals & CMS Case Coordinator

Private Health Administrators (Pty) Ltd; Centurion; On-site; ZAR 480,000 - 600,000; Full time

Job summary

Private Health Administrators (Pty) Ltd is seeking a clinical assessor to provide expert evaluation and decision support for ex gratia applications, CMS complaints, appeals and disputes. You will review clinical documentation, apply PMB regulations, and ensure compliant, well-motivated decisions.

Responsibilities include managing CMS escalations, drafting responses, liaising with providers and internal teams, and maintaining auditable case records in line with Medical Schemes Act.

Qualifications

• 2-5 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration industry or similar.
• Registered Nurse or Enrolled Nurse (Preferred) – Registered with SANC or Industry related qualification.

Responsibilities

• Review and assess clinical appeals and disputes in line with scheme rules and clinical guidelines
• Analyse clinical documentation, treatment plans, and provider motivations
• Make evidence-based recommendations on benefit funding and clinical appropriateness
• Ensure turnaround times (TATs) are adhered to
• Manage complaints and escalations received from CMS
• Compile detailed, accurate, and compliant case responses within required timelines
• Liaise with internal stakeholders to gather relevant clinical and administrative information
• Ensure alignment with the Medical Schemes Act and CMS rulings
• Evaluate ex-gratia requests based on clinical merit, financial impact, and member circumstances
• Prepare structured case summaries and recommendations for internal committees
• Interpret clinical data, ICD-10 codes, treatment protocols, and PMB regulations
• Apply managed care principles to ensure cost-effective and appropriate care
• Escalate complex or high-risk cases to senior clinical staff where necessary
• Communicate effectively with healthcare providers, members, and internal departments
• Provide clear, professional written responses for disputes and appeals outcomes
• Participate in multidisciplinary discussions and case reviews
• Ensure all decisions comply with Medical Schemes Act, PMB regulations, scheme rules and policies
• Maintain accurate and auditable records of all cases
• Support internal and external audits
• Keep up to date with operational changes implemented in response to external influences
• Deliver in a manner that supports operational quality standards

Skills

Appeals & Disputes Management

Clinical assessment

CMS case management

Stakeholder engagement

Regulatory compliance

Data analysis

Education

Registered Nurse (SANC) or related qualification

Job description

Private Health Administrators (Pty) Ltd is seeking a clinical assessor to provide expert evaluation and decision support for ex gratia applications, CMS complaints, appeals and disputes. You will review clinical documentation, apply PMB regulations, and ensure compliant, well-motivated decisions.

Responsibilities include managing CMS escalations, drafting responses, liaising with providers and internal teams, and maintaining auditable case records in line with Medical Schemes Act.