Fresh Vacancies at Government Employees Medical Scheme RSA

The position of Specialist Clinical Health Policy is vacant. The Specialist Clinical Health Policy will report directly to the Manager Clinical Health Policy and form part of the Healthcare Management division . The position is based at Head Office in Pretoria.

The total remuneration package for this position negotiable based on qualifications and experience.

The Specialist Clinical Health Policy will be required to assist and support the Manager Clinical Health Policy through the implementation of the following Key Performance Areas (KPAs):

• Assist and contribute to the conduction of targeted research into local and international clinical guidelines and funding policies to ensure that Scheme funding decisions are based on best practice.
• Assist in critically analysing clinical literature and use of evidence-based principles to review and generate enhancements in funding protocols to manage and monitor clinical cost targets.
• Assist in the development and maintenance of adequate knowledge of data handling and interpretation of information translating interventions.
• Assist in the review of the Scheme’s funding policies, protocols and formularies.
• Assist in improving member value.
• Assist in the process for development and maintenance of Medical Advisory Services standard operating procedures and policies.
• Assist the Medical Advisory Services unit in providing clinical support to Healthcare Management and the Scheme’s other divisions.
• Assist in providing clinical support to the Scheme’s Disease Risk Management Programmes and Maternity Benefit
• Manage relationship building with key stakeholders.
• Perform Service Level Agreement quarterly site visits
• Support in the management and monitoring of SPNs to implement and give results within set targets
• Assist in the process for development and maintenance of Medical Advisory Services standard operating procedures and policies.

Qualification requirements are:

• Minimum 4-year Diploma / Degree in Medical Sciences or related fields
• Qualifications in Health Technology Assessment or Evidence-Based Medicine would be advantageous
• At least three (3) years of work experience in the healthcare funding / medical scheme industry
• Previous experience in a Health Policy Unit will be advantageous.
• Experience in the evaluation of health technology assessments would be advantageous.
• Must have experience in the development and presentation for reporting purposes.
• A good understanding of coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more)
• A good understanding of the South African Healthcare Industry
• A good understanding of the Medical Schemes Act
• The ability to conduct research using a variety of academic and market-related resources

Desirable:

• Sound understanding of the medical schemes industry 

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The position of Senior Manager: Medical Advisory Services is vacant. The Senior Manager: Medical Advisory Services will report directly to the Chief Healthcare Officer and form part of the Healthcare Management division. The position is based at Head Office, Pretoria.

 The total remuneration package will be based on qualifications and experience.

 The Senior Manager: Medical Advisory Services will be required to support the Chief Healthcare Officer through the implementation of the following Key Performance Areas (KPAs):

• Assist the Chief Healthcare Officer in executing all clinical and medical advisory services within the Healthcare Management division and maintain clinical oversight on all aspects of the Scheme’s business.
• Ensure that the execution of clinical and medical advisory services within GEMS are sound and in compliance with the Medical Schemes Act and Regulations and the Scheme Rules.
• Conduct systemic reviews of evidence-based clinical practice guidelines and ensuring that Scheme funding decisions are based on best practice.
• Manage the activities of the Scheme’s Expert Advisory Panels that assist in maintaining the Scheme's evidence-based clinical protocols.
• Timeously review and make funding decisions and/or recommendations on the Scheme’s Ex Gratia ratification cases using evidence-based medicine.
• Manage and maintain the Scheme’s Ex Gratia guidelines.
• Provide clinical expertise and support to the Scheme’s Ex Gratia Committee and Sub-Committee.
• Oversee the Scheme’s Maternity Programme and ensure strategic objectives are achieved.
• Oversee the Pathology & Radiology Benefits Management, including, but not limited to, claims management and clinical review of billing rules and tariff files.
• Establish new alternative re-imbursement arrangements (ARMs) and value-based reimbursement arrangements in maternity, pathology, radiology, and high-cost medicines/biologics.
• Review and ensure CMS circulars are responded to and timeously implemented.
• Review and provide written responses on the clinical aspects of all CMS complaints, appeals, and all other complaints timeously.
• Attend and participate in various Scheme Forums and make valuable contributions by providing the expertise needed to provide strategic and clinical advisory services.
• Provide clinical expertise and support to the Scheme’s Divisions, as well as business units within the Healthcare Management division.
• Represent the Scheme and actively participate in all external stakeholder forums, conferences, etc.
• Support the Scheme’s strategic objectives and mandates. This includes elements of innovation that are key to the Scheme’s objectives.

Qualification requirements are:

• MBCHB as a minimum qualification. Must be registered with the Health Professions Council of South Africa (HPCSA).
• Minimum 5 years of work experience in the medical aid/managed care industry.
• Minimum 4 years as Manager / Senior Manager in the managed care/ medical aid industry.
• Experience in Clinical and Financial Risk Management.
• Benefit Design Experience.
• Must be in possession of a valid driver’s license and own vehicle and be willing to travel at short notice.
• A good understanding of all coding (Nappi, Tariffs, ICD10, CPT4, UPFS, and more).
• The ability to conduct research using a variety of academic and market-related resources.
• Essential skills:
  • Have a good understanding of GEMS Rules, Benefit Design, as well as administrative and managed care protocols;
  • Have a good understanding of the South African healthcare industry, the Medical Schemes Act, and other legislation;
  • Be organised and have good time management skills;
  • Be analytical and have the ability to manage priorities;
  • Have excellent written and verbal communication skills;
  • Have good interpersonal skills;
  • Have the ability to work well as part of a team;
  • Be computer literate on advanced levels;
  • Be responsible and reliable;
  • Have a diligent work ethic with attention to detail;
  • Be self-motivated and pro-active;
  • Have strong negotiation skills;
  • Work well under pressure.

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The position of Manager External Stakeholder Support  is vacant. The Manager External Stakeholder Support will report directly to the Senior Manager Medical Advisory Services and form part of the Healthcare Management division . The position is based at Head Office in Pretoria.

The total remuneration package for this position negotiable based on qualifications and experience.

The Manager External Stakeholder Support will be required to assist and support the Senior Manager Medical Advisory Services through the implementation of the following Key Performance Areas (KPAs):

• Manage the administrative function in the Medical Advisory Services business unit
• Contribute to and conduct targeted research into local and international clinical guidelines and funding policies.
• Critical review and analysis of current cost drivers and trends and compare with those of local and international sources for best practice.
• Assist in the management and monitoring of clinical cost targets
• Assist in developing and maintaining adequate knowledge of data handling and interpretation of information translating interventions.
• Chair and coordinate monthly SPN meetings
• Perform Service Level Agreement quarterly site visits
• Support in the management and monitoring of SPNs to implement and give results within set targets
• Support in the management of divisional budget in line with budget allocation
• Assist in improving member value
• Monitor project/programme in conjunction with the internal Project Management Unit of the Scheme
• Ensure that all relevant projects are carried out and finalised
• Liaise with GEMS SPNs on operational matters
• Represent the Healthcare Management Division at SPN and External Stakeholder Engagements, including but not limited to GEMS Provider Summits, industry conferences, member Makgotlas, SAPS, BHF, DPSA, various other external stakeholders
• Represent the Healthcare Management in external stakeholder events
• Assist in the process for development and maintenance of Medical Advisory Services standard operating procedures and policies.
• Assist the Medical Advisory Services in providing clinical support to Healthcare Management and the Scheme’s other divisions in their external stakeholder-related matters
• Support Provider Relations and Network engagements (quarterly hospital efficiency, provider society and groups and other forums as required).
• Clinical review of hospital and provider efficiency and network reports.
• Advise the Scheme on existing and new alternative reimbursement models received from external stakeholders

Qualification requirements are:

• Minimum MBChB/ MBBCh. Must be registered with the HPCSA
• Qualifications in Health Technology Assessment or Evidence-Based Medicine would be advantageous
• At least five (5) years work experience in the healthcare funding / medical scheme industry with at least two (3) years at manager/supervisor level
• Experience in the evaluation of health technology assessments would be advantageous
• Must have experience in the development and presentation of management reports
• A good understanding of coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more)
• A good understanding of the South African Healthcare Industry
• A good understanding of the Medical Schemes Act
• The ability to conduct research using a variety of academic and market-related resources

Desirable:

• Sound understanding of the medical schemes industry 

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The position of Senior Manager: Finance  is vacant. The Senior Manager: Finance will report directly to the Chief Financial Officer and will be based at Head Office, Pretoria.

The total remuneration package will be will be based on qualifications and experience.

The Senior Manager: Finance will be required to support the Chief Financial Officer: through the implementation of the following KPA’s

Key Performance Areas (KPAs):

• Managing the scheme's finances efficiently including budgeting, forecasting, financial planning, cash flow, claims liability etc.
• Implementing and overseeing the scheme's investment portfolio to optimize returns within approved risk levels.
• Actuarial Partnership- working closely with actuaries on pricing, reserving, modeling, and benefit design.
• External Audit - Managing the external audit process and resolution of audit queries.
• Ensure accurate and timely financial statements, regulatory reporting, and management reporting.
• Review and analyse monthly management accounts and report effectiveness of premium collection and debt management;
• Review and finalise AFS for each financial year in line with IFRS, Council for Medical Schemes and SAICA;
• Manage external audit sign off of AFS and annual return submission to CMS
• Compliance and Governance - Ensuring adherence to all relevant laws, regulations and ethical standards for financial management and reporting
• Financial Stewardship - Maintaining integrity, transparency, controls and oversight to enable sound financial decision making.
• Leading, managing, and developing the finance team – driving performance

Qualification requirements are:

• Post degree qualification in finance/accounting (preferably CFA/CA/newly qualified CA) and completed articles
• Possess scientific report writing report skills
• Minimum 5 years financial management experience at senior level and 8 years functional experience
• Experience in investments is preferable

Behavioural Competencies

• Strong actuarial acumen with the ability to interpret and apply actuarial analysis to strategic financial decisions.
• Strategic thinking skills to evaluate financial options and optimize outcomes based on the big picture.
• Excellent communication and collaboration skills to engage diverse stakeholders and unify teams behind objectives.
• Sharp analytical abilities to transform financial data into strategic insights.
• Meticulous attention to detail and commitment to accuracy in all financial matters.
•  Strong ethics and integrity with a focus on good governance and transparency.
• Critical thinking skills to get to the root of issues and weigh alternatives.
• A collaborative approach to align financial strategy across the organization.
• Commercial acumen to drive profitability, efficiency and optimal financial performance.
• Proven people management skills to lead high-performing finance teams.

Desirable

•  Have an understanding of the medical schemes industry as well as the national health system