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)
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)
Clinical coding knowledge of ICD -10