Medical Advisor - Centurion at PPS

Minimum Requirements    

• Must be a Medical Doctor registered with Health Professions Council of South Africa (HPCSA).
• Medical indemnity insurance will be an added advantage.
• Must have sound knowledge of the Medical Aid Industry, Rules & Regulations, and other related legislation.
• Sound knowledge of PMB guidelines and Industry knowledge would be an added advantage.
• Excellent business writing & communication skills with exceptional telephone etiquette.
• Must have strong organisational awareness in order to anticipate the impact of actions on other groups.
• Time Management & good administration skills.
• Effective conflict resolution skills and the ability to work under pressure.
• Must be a strong team player and results driven.
• Computer literacy (MS Office).

Duties and Responsibilities    

• Advise the Managed Healthcare (MHC) group on clinical matters pertaining to, pre-authorization, case management, benefit management e.g. PMB’s, disease management and pharmaceutical benefit management, non disclosures etc. in order to ensure clinical appropriateness of benefits.
• Recommend various internal groups and the Scheme on clinical matters to ensure that the rules of the Scheme has been correctly applied and implemented.
• Assess individual cases in accordance with that diagnoses and clinical data motivation letter/benefit structure/Rules of the Scheme/clinical knowledge/experience to facilitate clinical appropriateness of benefits.
• Assist with the development, implementation and maintenance of Clinical protocols and internal processes for the MHC group to ensure consistency in the application of benefits.
• Facilitate and provide clinical training to the MHC group to ensure the continuous updating of clinical knowledge and skills, as well as medical advancements.
• Amend appropriate training material as required to ensure the most up to date clinical information is available.
• Attend meetings, interdepartmental forums, benefit design workshops, third party representatives and the Scheme to provide clinical input and expertise where it may be required.
• Attend the Medical Advisory Group meetings/ conferences for the adoption of clinical policies and to keep abreast of industry trends, developments and norms.
• Research scientific clinical data in order to source advancements to keep abreast of industry trends, developments and norms and advise the Scheme on benefit design and reimbursements.
• Consult with medical specialists and professional bodies to obtain their expert opinions.
• Recommend alternative treatment plans using physician’s motivation letter/Benefit structure/Rules of the Scheme to ensure the most cost-effective treatment.
• Liaise with service providers to exchange information and discuss referred cases.
• Refer appeals to the Clinical Committee for a final decision and compile the official reply to the complainant in order to adjudicate the Clinical Committee's decision.
• Review and respond to clinical queries from CMS.
• Oversee the high cost strategy for the schemes, deal with alternate drug reimbursement models and oversee the policy management.