Job Description

Purpose

The purpose of the job is to oversee the provision of Clinical services, administer the Prescribed minimum benefits portfolio to ensure medical scheme members are protected and their entitlements are guaranteed, and to develop and implement the prescribed minimum benefits regulation strategy.

Main duties

1. Driving the implementation of clinical consulting services planned activities and projects:

• Oversee the functioning of the clinical consulting services sub-division by managing the sub-division projects and day-to-day function of the clinical unit including performance management, development, and implementations of operational plans.
• Facilitate clinical support to other sub-division such as benefits management, research & monitoring, legal services etc.

2. Coordinating and participating in the development of prescribed minimum benefit definition and review:

• Participate in the development of PMB definition and review by applying a combination of clinical, financial and health economic skills.
• Support the analysis of scheme risk measurement with epidemiological input (analyses and interpretation of disease trends and costs.

3. Adjudication of clinical opinions:

• Adjudication of clinical opinions:
• To oversee the provision of evidence based, quality and meticulous clinical opinions.
• To provide feedback on clinical enquiries and opinions to external stakeholders.

4. Coordinate Clinical Review Committee:

• To coordinate clinical review committee meetings, monitor, report and manage clinical review committee activities.
• To participate in the appeals committee and provide clarity to the appeal committee on clinical opinions that informs rulings.

5. Provide support to National Department of Health:

• To attend meetings and provide inputs to National Department of Health committees related to the company's work.
• To implement ad-hoc national health policy projects and provide policy directive.

6. Undertake assignments/tasks allocated by line manager in accordance with the company operational requirements.

Minimum requirements

• Bachelor of Medicine and Bachelor of Surgery (MBChB) / Degree in Medicine with post Graduate Training in Epidemiology and Public Health at NQF level 8.
• Masters Degree Qualification in Public Health will be an added advantage.
• Completed Internship and Community Service.
• A Valid Health Professional Council of South Africa (HPCSA) Certificate.
• A minimum of 12 years relevant experience in the Medical Schemes and / Healthcare environment, of which 5 years must be in Evidence-Based Medicine & Clinical Management, and 7 years at Management/Supervisory level.
• Computer Literacy.

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