Clinical Appeals & Compliance Liaison

Private Health Administrators (Pty) Ltd

Centurion

On-site

ZAR 700,000 - 1,100,000

Full time

10 days ago

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Job summary

Private Health Administrators (Pty) Ltd in Centurion seeks an experienced clinician to provide expert assessment and decision support for ex-gratia applications, CMS complaints, appeals and disputes. You will evaluate clinical data, PMB compliance and prepare structured summaries for committees.

Collaborative engagement with providers and members is essential to ensure timely, well-supported outcomes. The role emphasizes evidence-based decision making, governance compliance, and maintaining

Qualifications

Review and assess clinical appeals and disputes according to scheme rules and guidelines.
Analyse clinical documentation, treatment plans and provider motivations.
Provide evidence-based recommendations on benefit funding and clinical appropriateness.
Ensure timely turnaround times for all cases.

Responsibilities

Manage CMS complaints and escalations with strict adherence to required timelines.
Compile accurate, compliant case responses and liaise with internal stakeholders.
Evaluate ex-gratia requests based on clinical merit, financial impact and member circumstances.
Interpret ICD-10 codes, PMB regulations and treatment plans to support decisions.
Provide clear written feedback and participate in multidisciplinary case reviews.

Skills

Appeals & disputes

CMS case management

Ex-gratia review

Clinical assessment

Stakeholder engagement

Compliance & governance

Education

Industry related qualification

Job description

Collaborative engagement with providers and members is essential to ensure timely, well-supported outcomes. The role emphasizes evidence-based decision making, governance compliance, and maintaining

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