Jobs in Canada

To process clinical authorizations on various benefit types e.g., chronic, oncology, HIV rules etc for members of the medical schemes.

Implement and maintain Medical Scheme rule changes as and when they occur.

To evaluate and authorise a minimum of 30 medicine applications according to scheme rules and clinical protocols SLA requirements (SLA of at least 80% and Service Level Efficiency (SLE) of at least 90%) following the process noted:

• Receives application via email or telephone and capture data on ChroniLine system
• Apply scheme rules and protocol: Complete authorization and provide feedback depending on method application received
• Ensure all information is recorded and noted on the ChroniLine system and filed as per SOP by completion of the authorization
• Escalate applications to specialist authorization team in order to facilitate medicine authorisations within SLA requirements

• Assist pharmacist assistants with clinical decision making for escalated queries.
• Identify training and development needs of the Pharmacy Assistant and advise the Manager, Managed Care of the training need.
• Liaise and meet with clients and provide guidance and advice regarding medicine benefit design and medicine claims management at least once per annum.
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• Ensure that escalated queries are resolved timeously.

• Explain medical scheme rules to doctors, pharmacists, members of medical schemes and other parties in a courteous, professional manner.
• Resolve queries from allocated clients in line with SLA and SOP.
• Maintain and communicate medical scheme rules (note and sign-off documents) to relevant stakeholders within 24 hours of receipt.

• Compile documentation for medical schemes.
• Assist with scheme take-on's if required.
• Assist departmental head, as and when requested, with other functions within the Managed Care department.

• Bachelor of Pharmacy (B.Pharm)
• Registered with the SA Pharmacy Council
• Minimum 1 year's experience in the health care or medical aid industry or Retail / courier pharmacy experience
• Previous experience performing DURs, clinical pharmacy work, or related roles
• Post-qualification experience in hospital, managed care, insurer, or pharmacy benefit environment.
• Understanding of medical aid schemes and formulary management.

• Sound knowledge of Drug Utilization Review.
• Knowledge of the medical scheme and managed care industry.
• Sound knowledge of the pharmacy / pharmaceutical industry.
• Good knowledge of various legislation concerning medical schemes, health insurance, PMBs, and other healthcare issues.
• Excellent verbal and written communication skills.
• Analytical and detail orientated.
• Interpersonal and customer-orientated service skills.
• Ability to work independently and in a multidisciplinary project team.
• Handle pressure and difficult situations.
• Be able to work under set deadlines – time management is critical.
• Be responsible and able to maintain confidentiality.

Recruitment will be done a per Company EE plan

Seniority level
Entry level

Employment type
Full-time

Job function
Health Care Provider

Industries
Health and Human Services

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