Clinical Manager

Clinical Manager

About Discovery

Discovery’s core purpose is to make people healthier and to enhance and protect their lives. We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery. Our fast-paced and dynamic environment enables smart, self-driven people to be their best. As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.

About Clinical Benefit Advisory Team

The Clinical Benefit Advisory Team (CBAT), a subsidiary of Discovery Health, comprises Medical and Legal Advisors who offer clinical and legal expertise on complex cases. The Council Liaison Managers serve as the bridge between Discovery Health and the Council for Medical Schemes, providing support to the Legal Advisors. Additionally, the Medical Review Consultants ensure that clinical cases are thoroughly reviewed, and appropriate decisions are made. The team operates regionally in Sandton and Cape Town.

Key Purpose:

This position requires the successful candidate to be able to make funding decisions for clinically complex cases as per the scheme rules, in keeping with principles of evidence-based medicine while promoting cost effective and quality healthcare for our members and managing interactions with external clinical providers, and to provide clinical support, knowledge, insight, and leadership to the clinical Services environment. Clinical training co-ordination for CS and MRT.

Key Outputs:

The successful applicant will be responsible for but not limited to the following job functions:

• Providing clinical support to the medical review team, executive offices, medical advisors, and other business areas like In-hospital CRMs, pre-auth and PMB teams
• Constant interaction and relationship building with external health care providers, and communication with external expert panelists
• Ensuring the workflow pools and TWT are met
• Evaluation and resolution of PMB escalations, claims queries escalations, clinical escalations, oncology escalations, Cleveland case review and executive escalations.
• Ensure that all complaints escalated are comprehensively investigated and responded to timeously (as set and reviewed periodically by the Departmental Manager)
• Unpacking and investigation of complex cases referred for review from CAS/ECR and feedback to ECR as required or other relevant business areas as required
• Establishing and maintaining relationships and liaison with internal stakeholders including CCE, ISEM, Risk and others, and ensuring maximum support from these business areas that the team relies on to resolve clinical matters
• Referral of cases to CCE for Quick Search/Full Clinical evidence Evaluation
• Maintaining data and knowledge bases on SharePoint
• Facilitate appropriate training and skills development to meet business objectives.
• Creation of ALERTS to guide decision making regarding funding of various treatments for Clinically Complex Cases
• Arrangement of Training to upskill the Clinical Services area, e.g., arranging both internal and external specialist talks on subjects of clinical interest.

Competencies:

The successful candidate must demonstrate the following competencies:

Education and Experience:

The following requirements are essential:

• Health related qualification and appropriate Medical/Clinical training (professional nurse, physiotherapy, emergency medical services, occupational therapist)
• Valid registration with the relevant professional body
• More than 8 years’ industry experience
• Extensive experience within Discovery Health Clinical Departments including oncology
• Knowledge of Discovery Health Product and Protocols

The following requirements are advantageous:

• At least 3 years’ experience in MRT
• A minimum of 1 years’ experience as a senior MRT/at least 1 year as a clinical specialist in the Medical Advisory team

EMPLOYMENT EQUITY   
                             
The Company’s approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.