Job Description

SUMMARY:
Manager Clinical Stakeholder Support (Internal) Medical Doctor - Medical Scheme - PretoriaPOSITION INFO:Key Performance Areas (KPAs):xc3xbc Manage the administrative function in the Medical Advisory Services business unitxc3xbc Contribute to and conduct targeted research into local and international clinical guidelines and fundingpolicies.xc3xbc Critical review and analysis of current cost drivers, and trends and compare with those of local andinternational sources for best practice.xc3xbc Assist in the management and monitoring of clinical cost targetsxc3xbc Assist in developing and maintaining adequate knowledge of data handling and interpretation of informationtranslating interventions.xc3xbc Support the Medical Advisory Services Unit in the Schemes product development and benefit designactivitiesxc3xbc Chair and coordinate monthly SPN meetingsxc3xbc Perform Service Level Agreement quarterly site visitsxc3xbc Support in the management and monitoring of SPNs to implement and give results within set targetsxc3xbc Support in the management of the divisional budget in line with budget allocationxc3xbc Assist in improving member valuexc3xbc Monitor project/programme in conjunction with the internal Project Management Unit of the Schemexc3xbc Ensure that all relevant projects are carried out and finalisedxc3xbc Liaise with SPNs on operational mattersxc3xbc Represent the Healthcare Management Division at SPN and Stakeholder Engagementsxc3xbc Represent the Healthcare Management division in internal forumsxc3xbc Assist in the process for development and maintenance of Medical Advisory Services standard operatingprocedures and policies.xc3xbc Provide clinical oversight and support to the Schemes internal processes, and support to the Schemesother divisions in functions such as claims risk management, complaints process, health and wellnesscampaigns, and outgoing Scheme communicationxc3xbc Assist in the resolution of all complaints; Council of Medical Scheme, internal escalations, Provider Relations,and other complaintsxc3xbc Assist in the review of Competition Commission submissionsxc3xbc Pathology & Radiology Benefit Management including, but not limited to, review of billing rules and tariff filesxc3xbc Advise the Scheme on existing and new alternative reimbursement modelsxc3xbc Provide clinical support in the review of Tariff and Billing rulesxc3xbc Provide clinical support in the management of the Schemes ambulatory, hospital and medicine benefitsxc3xbc Evaluation and analysis of proposals submitted to the Scheme and provide recommendations, including,xc3xbc but not limited to: analysis of proposed appliances reimbursement, ARMS and value-based care models.xc3xbc Provide clinical advice and recommendations for the identified strategic sourcing interventionsRequirementsxc3xbc Minimum MBChB/ MBBCh. Must be registered with the HPCSAxc3xbc Qualifications in Health Technology Assessment or Evidence-Based Medicine would be advantageousxc3xbc At least five (5) years work experience in the healthcare funding / medical scheme industry with at least two(2) years at manager/supervisor levelxc3xbc Experience in the evaluation of health technology assessments would be advantageousxc3xbc Must have experience in the development and presentation of management reportsxc3xbc A good understanding of coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more)xc3xbc A good understanding of the South African Healthcare Industryxc3xbc A good understanding of the Medical Schemes Actxc3xbc The ability to conduct research using a variety of academic and market-related resourcesDesirablexc3xbc Sound understanding of the medical schemes industry

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