Medical Advisor

AfroCentric Group; Wes-Kaap; On-site; ZAR 800,000 - 1,000,000; Full time

Job summary

A healthcare management organization in South Africa is looking for a medical professional to protect scheme funds from over-utilisation and inappropriate claims. Responsibilities include providing clinical inputs, engaging with providers, and assessing high-risk medical procedures. Ideal candidates should have an MBChB degree and 6-8 years of managed care experience. Strong analytical and communication skills are essential, along with a focus on customer service.

Qualifications

• 6 - 8 years Managed Care experience preferred.
• Knowledge and application of relevant legislation.
• Knowledge of the device industry.

Responsibilities

• Provide clinical inputs on ex-gratia funding requests.
• Engage with providers and pre-authorisation agents to build relationships.
• Assess all high risk medical procedures for authorisation.

Skills

Analytical skills

Business Writing Skills

Communication Skills

Computer Technology Skills

Attention to Accuracy and Detail

Problem solving and decision making skills

Numerical Ability

Customer Focus

Education

Relevant medical degree (MBChB)

Job description

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.

Qualifications

Relevant medical degree, relevant qualification should be a MBChB degree.

Experience

6 - 8 years Managed Care experience preferred

Accountabilities

• Continuous improvement:
  • Provide clinical inputs on ex-gratia funding requests
  • Open, review and resolve all clinical queries and assessments through providing a clinical decision or requesting more information where required
  • Implement practical solutions that use the specialist and departmental systems and processes
  • Provide specialist input and recommendations to improve the efficiency, compliance and quality objectives related to the area of specialisation
  • Identify problems and develop and propose solutions to present to appropriate leader or stakeholders
  • Ensure day to day operational support required from area of specialisation is provided to enhance performance
• Cost containment:
  • Support the identification, development and implementation of cost-effective processes to increase efficiency and reduce cost drivers related to area of specialisation
  • Continuously review cost / benefit and Return on Investment within area of specialisation
• Drive customer-centricity:
  • Engage with providers and pre-authorisation agents to build informed and supportive mutual relationships
  • Maintain a high level of impact on other departments to support improved delivery
  • Continually increase understanding of client and stakeholder needs, satisfaction and service delivery.
• Knowledge management:
  • Assess all high risk or high cost medical procedures to ensure appropriate authorisation and claiming is facilitated
  • Provide clinical training / support to identified stakeholders
  • Provide medical advisory services to relevant parties
  • Ensure that adequate knowledge regarding specialisation is shared as required and maintained within the research library
  • Provide advice and / or training as required
  • Maintain, develop and implement specialist knowledge within the day to day operations of the organisation.
• Maintain expertise level:
  • Be a member of related professional bodies
  • Ensure CPD (continual professional development) or similar accreditation requirements are met annually to ensure maintained specialist accreditation.
• Network key relationships:
  • Engage with and provide support to the established network of internal and external expert resources and partners.
• Specialist support to projects:
  • Provide Specialist expertise and ensure best practice related to specialisation is implemented in projects, when required
  • Conform to project management disciplines when participating in projects
  • Represent department or project on appropriate committees related to area of specialisation.

Competency Requirements

• Knowledge:
  • Knowledge and application of relevant legislation
  • Knowledge of device industry
  • Ability to provide appropriate medical direction and advisory services
  • Knowledge and application of clinical principles and processes
  • Knowledge of clinical and funding protocol development
  • Clinical research and assessment
  • Knowledge of scheme rules and contractual negotiations
• Skill:
  • Analytical skills
  • Business Writing Skills
  • Communication Skills
  • Computer Technology Skills
  • Attention to Accuracy and Detail
  • Problem solving and decision making skills
  • Numerical Ability
  • Customer Focus