Medical Advisor

AfroCentric Group; Wes-Kaap; Presencial; ZAR 900.000 - 1.350.000; Jornada completa

Descripción de la vacante

AfroCentric Group in South Africa seeks a senior Managed Care Specialist to ensure protected funding decisions and to provide expert clinical input. You will assess high-risk procedures, resolve complex queries, monitor utilisation trends, and collaborate with pre-authorisation teams to optimise outcomes.

MBChB qualified with 8 years of managed care experience preferred; strong knowledge of healthcare legislation and governance is required.

Formación

• MBChB qualification and registration with a professional council.
• 8 years of managed care experience preferred.
• Strong clinical decision-making and evidence-based guidance.

Responsabilidades

• Assess and provide clinical recommendations on high-risk, high-cost procedures to support funding decisions.
• Review and resolve complex clinical queries and medical assessments with evidence-based guidance.
• Evaluate ex-gratia funding requests and provide input for fair decisions.
• Provide expert medical advisory services to internal stakeholders and providers.
• Identify inappropriate utilisation and trends affecting member funds.
• Support development and review of clinical funding protocols and policies.
• Engage with providers and pre-authorisation teams to facilitate outcomes.
• Provide clinical training and coaching to internal teams.
• Contribute medical expertise to governance structures and committees.
• Identify opportunities for continuous improvement in quality and cost-effectiveness.
• Analyse clinical data to support cost-containment and better funding outcomes.
• Ensure compliance with healthcare legislation and governance requirements.

Conocimientos

Managed Care

Educación

MBChB

Descripción del empleo

Position Purpose: To ensure that the scheme or organisation is protected from over-utilisation or inappropriate claiming by service providers that leads to abuse of member and scheme funds.

Experience: 8 years Managed Care experience preferred

Qualifications: MBChB

Position Specific Outputs and generic objectives:

• Assess and provide clinical recommendations on high-risk and high-cost medical procedures to support appropriate funding and authorisation decisions.
• Review, evaluate and resolve complex clinical queries and medical assessments, providing evidence-based clinical decisions and guidance.
• Evaluate ex-gratia funding requests and provide clinical input to support fair and consistent decision-making.
• Provide expert medical advisory services to internal stakeholders, healthcare providers and other relevant parties.
• Monitor and identify inappropriate utilisation, abuse or over-servicing trends that may negatively impact member and scheme funds.
• Support the development, implementation and review of clinical funding protocols, policies and managed care initiatives.
• Engage with healthcare providers, specialists and pre-authorisation teams to build effective relationships and facilitate optimal clinical outcomes.
• Provide clinical training, coaching and support to internal teams and stakeholders to enhance clinical knowledge and decision quality.
• Contribute specialist medical expertise to projects, governance structures and committees to ensure alignment to industry best practice.
• Identify opportunities for continuous improvement and recommend solutions that enhance quality, compliance, efficiency and cost-effectiveness.
• Analyse clinical and utilisation data to support cost-containment initiatives and improve healthcare funding outcomes.
• Ensure compliance with applicable healthcare legislation, medical scheme rules, clinical governance requirements and industry standards.
• Maintain professional registration and continuous professional development requirements to ensure ongoing clinical expertise and credibility

The shortlisting process will only start once the application due date has been reached. The time taken to complete this process will depend on how far you progress and the availability of line managers.

Our Commitment to Transformation

AfroCentric is committed to transformation and embracing diversity. Our Employment Equity plan and targets will be considered as part of the recruitment process. This commitment is what drives us to achieve a diverse workplace with employment equity as a key goal to create an inclusive workforce, representative of the demographics of our society as well as people with disabilities.

Should you not hear from us within a month of applying, consider your application unsuccessful.