Key Purpose:

• This position requires the successful candidate to be able to make funding decisions for clinically complex cases as per scheme rules, in keeping with principles of evidence based medicine while promoting cost effective and quality healthcare for our members and managing interactions with external clinical providers.

Key Outputs:

The successful applicant will be responsible for but not limited to the following job functions:

• Provide clinical support to the Medical Review team, PMB team, Chronic Illness Benefit, hospital case management, oncology case management, exec office, benefit compliance review, the underwriting and forensics area, as well as other business areas.
• Ensuring the workflow pools and TWT are met
• Participating in key clinical forums internally and externally
• Daily Clinical Review – Preparing of cases, case presentation, loading member remarks and clinical exceptions, arranging second opinions/external expert opinion and follow up
• Communication of funding decisions to the relevant parties
• Keeping abreast with legislative and industry changes and how it affects your business unit
• Keeping updated with the latest clinical thinking and attending CPD events
• Identification of new trends in Medical Industry, and engagement with relevant clinical stakeholders
• Constant interaction and relationship building with external health care providers
• Maintenance of database of funding decisions made
• Support to Junior Staff and other Medical Advisors
• Knowledge of Claims, coding and assisting in getting payment resolutions
• Identify operational gaps and initiate improvement strategies
• Clear knowledge of evidence based medicine and the application thereof
• Review of clinical evidence on a case by case basis
• Liaison with various business group TWGs

Knowledge and Skills:

• Knowledge of Managed Care Environment
• Sound knowledge of Prescribed Minimum Benefits
• Excellent written and verbal communication skills in English
• Basic computer Literacy in Microsoft Office applications (must be proficient in Excel)

Competencies:

The successful candidate must demonstrate the following competencies:

Role Specific Behaviours

• Ensures accountability.
• Action oriented
• Manages ambiguity.
• Attracts top talent.
• Business insight
• Collaborates
• Communicates effectively.
• Manages complexity.
• Manages conflict.
• Courage
• Customer focus
• Decision quality
• Develops talent
• Values differences
• Directs work.
• Drives engagement
• Financial acumen
• Global perspective
• Cultivates innovation.
• Interpersonal savvy
• Builds networks.
• Nimble learning
• Organizational savvy
• Persuades
• Plans and aligns.
• Being resilient
• Resourcefulness
• Drives results
• Demonstrates self-awareness.
• Self-development
• Situational adaptability
• Balances stakeholders
• Strategic mindset
• Builds effective teams.
• Tech savvy
• Instils trust.
• Drives vision and purpose
• Optimizes work processes

Education and Experience:

The following requirements are essential:

• Matric
• Qualified Medical Doctor
• Full and Current HPCSA registration – Independent Practice
• Minimum of two years experience in a Private hospital or clinic

The following requirements will be advantageous:

• Previous Medical Advisor or managed healthcare experience
• Knowledge of DH SOP’s and Process experience (internal only)
• Provider payment arrangements (internal Only)
• Clinical coding knowledge of ICD-10 and/or CCSA

Personal Attributes or Competency Profile

The Discovery Person

• Values Driven
• Optimistic
• Learns on the Fly
• Resilient
• Instils Trust
• People Savvy
• Drives Results
• Problem Solver