Key Performance Areas (KPAs):
ü Manage the administrative function in the Medical Advisory Services business unit
ü Contribute to and conduct targeted research into local and international clinical guidelines and funding
policies.
ü Critical review and analysis of current cost drivers, and trends and compare with those of local and
international sources for best practice.
ü Assist in the management and monitoring of clinical cost targets
ü Assist in developing and maintaining adequate knowledge of data handling and interpretation of information
translating interventions.
ü Support the Medical Advisory Services Unit in the Schemes product development and benefit design
activities
ü Chair and coordinate monthly SPN meetings
ü Perform Service Level Agreement quarterly site visits
ü Support in the management and monitoring of SPNs to implement and give results within set targets
ü Support in the management of the divisional budget in line with budget allocation
ü Assist in improving member value
ü Monitor project/programme in conjunction with the internal Project Management Unit of the Scheme
ü Ensure that all relevant projects are carried out and finalised
ü Liaise with SPNs on operational matters
ü Represent the Healthcare Management Division at SPN and Stakeholder Engagements
ü Represent the Healthcare Management division in internal forums
ü Assist in the process for development and maintenance of Medical Advisory Services standard operating
procedures and policies.
ü Provide clinical oversight and support to the Schemes internal processes, and support to the Schemes
other divisions in functions such as claims risk management, complaints process, health and wellness
campaigns, and outgoing Scheme communication
ü Assist in the resolution of all complaints; Council of Medical Scheme, internal escalations, Provider Relations,
and other complaints
ü Assist in the review of Competition Commission submissions
ü Pathology & Radiology Benefit Management including, but not limited to, review of billing rules and tariff files
ü Advise the Scheme on existing and new alternative reimbursement models
ü Provide clinical support in the review of Tariff and Billing rules
ü Provide clinical support in the management of the Schemes ambulatory, hospital and medicine benefits
ü Evaluation and analysis of proposals submitted to the Scheme and provide recommendations, including,
ü but not limited to: analysis of proposed appliances reimbursement, ARMS and value-based care models.
ü Provide clinical advice and recommendations for the identified strategic sourcing interventions
Requirements
ü Minimum MBChB/ MBBCh. Must be registered with the HPCSA
ü Qualifications in Health Technology Assessment or Evidence-Based Medicine would be advantageous
ü At least five (5) years work experience in the healthcare funding / medical scheme industry with at least two
(2) years at manager/supervisor level
ü Experience in the evaluation of health technology assessments would be advantageous
ü Must have experience in the development and presentation of management reports
ü A good understanding of coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more)
ü A good understanding of the South African Healthcare Industry
ü A good understanding of the Medical Schemes Act
ü The ability to conduct research using a variety of academic and market-related resources
Desirable
ü Sound understanding of the medical schemes industry
