Senior Clinical Utilization & Funding Advisor

AfroCentric Group; Wes-Kaap; On-site; ZAR 900,000 - 1,350,000; Full time

Job summary

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.

Qualifications

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

Responsibilities

• 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.

Skills

Managed Care

Education

MBChB

Job description

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.