Medical Scheme: Medical Adviser (Gauteng)

Experience required: You would have gained experience in working directly for a medical schemes service provider - average of 4 years

Managed Care organisation seeks Medical Advisor for management of clinical risks, cost-effectiveness and coordinating suitable use of scheme benefits

Key Requirements, But Not Limited To

MB Ch.B. degree & registered with the HPCSA - non negotiable
Estimate 4 years' experience gained in the medical scheme sector
You will have knowledge and understanding of Medical insurance industry & the Medical Schemes Act & Regulations as well as the Underwriting policies & procedures
You are accountable for benefit risk management
Ensure to investigate & recommend on application of certain clinical item codes, in collaboration with clinical coding specialist
Evaluate & authorise procedures & out-of-hospital benefits
Assist Case Management with clinical justification of hospital benefits, including appropriate levels of care and/or alternatives to hospital admission
Provide input regarding management of high-cost cases
Deliver clinical inputs on enquiries received from Council for Medical Schemes
Accountable for membership regulation
Specify inputs regarding underwriting for new members according to their clinical risk exposure
Inform the Risk business unit on clinical risks related with high claims & costs
Assist with queries received from New Business, members or advisers regarding pre-existing medical conditions & whether underwriting should be applied according to approved policy
Evaluate & supply inputs on requests for benefit option interchanges from a clinical perspective
Provide clinical advice when underwriting policies & guidelines are reviewed
Update underwriting policies in conjunction with Innovation and Risk business units
Assist with replies to the Council for Medical Schemes from a clinical perspective
Provide input on development of industry-standard guidelines
Provide feedback to Management on new clinical developments
Stay abreast of changes in clinical business landscape
Manage & implement managed care initiatives
Accountable for medical advisory services, including assisting with day-to-day case management enquiries & routine medicine enquiries
Partake in meetings requiring clinical input, such as high-cost meetings, clinical coding meetings, & out-of-protocol enquiries

To apply submit application to: response "at" [URL Removed] , supporting documentation required with CV application:

Ensure comprehensive CV with your responsibilities in factual bullet point form to showcase your relevant experience gained
Copies of all qualification/s including your Matric Certificate
Registration with HPCSA
Copy of your ID

Desired Skills