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