Minimum Requirements

• Nursing qualification.
• Clinical Auditing experience
• Minimum of 2 years’ experience in the managed care environment

Duties and Responsibilities

• Conduct clinical audits on claims and costs to ensure correct payment of claims to providers and members
• Accumulate/Investigate data using clinical experience to highlight risks and trends which might influence the costs to the scheme
• Compile audit reports to point out trends and risks
• Liaise with providers to develop and maintain relationships 
• Assist in the settlement of claims disputes to ensure correct payment of claims
• Research new medical and surgical instrumentation and products to keep the company abreast of changes in the industry
• Provide Clinical input into work directives and protocols to assist PMSA with clinical decisions
• Participate in negotiations with service providers in order to assist the Scheme with the cost effective management of resources
• Required to assist with the review of policies, protocols and formularies from a clinical and financial position
• Evaluate current medicine usage trends and compare with those of local and international sources for best practice
• Monitor medical literature and use evidence-based principles to generate enhancements in funding protocols
• Review and research new drug trial results, in collaboration with the Medical Advisor
• Answer clinical queries from Providers within the Schemes’ SLA requirements
• Perform tasks timeously and with necessary detail in response to issues raised
• Provide input and support to the Clinical Committees, MHC meeting and other committees as and when required
• Assisting with all adhoc requests on any clinical matters when required
• Maintain information gathered on knowledge management portals
• Proactively identify and manage potential problems/escalations within customer base with appropriate resolution plans