Medical Advisor - Talent Pool

Clinical Benefit Advisory Team

Medical Advisor

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 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.

Key Outputs:

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

• Provide clinical support to the Medical Review team, PMB team, Chronic Illness Benefit, hospital case management, oncology case management, exec office, benefit compliance review, the underwriting and forensics area, as well as other business areas.
• Ensuring the workflow pools and TWT are met
• Participating in key clinical forums internally and externally
• Daily Clinical Review – Preparing of cases, case presentation, loading member remarks and clinical exceptions, arranging second opinions/external expert opinion and follow up
• Communication of funding decisions to the relevant parties
• Keeping abreast with legislative and industry changes and how it affects your business unit
• Keeping updated with the latest clinical thinking and attending CPD events

Identification of new trends in Medical Industry, and engagement with relevant clinical stakeholders

• Constant interaction and relationship building with external health care providers
• Maintenance of database of funding decisions made
• Support to Junior Staff and other Medical Advisors
• Knowledge of Claims, coding and assisting in getting payment resolutions
• Identify operational gaps and initiate improvement strategies
• Clear knowledge of evidence based medicine and the application thereof
• Review of clinical evidence on a case by case basis
• Liaison with various business group TWGs

Knowledge and Skills:

• Knowledge of Managed Care Environment

• Sound knowledge of Prescribed Minimum Benefits

• Excellent written and verbal communication skills in English

• Basic computer Literacy in Microsoft Office applications (must be proficient in Excel)

Competencies:

The successful candidate must demonstrate the following competencies:

Education and Experience:

The following requirements are essential:

• Matric
• Qualified Medical Doctor
• Full and Current HPCSA registration - Independent Practice
• Minimum of two years experience in a Private hospital or clinic

The following requirements will be advantageous:

• Previous Medical Advisor or managed healthcare experience

• Knowledge of DH SOP’s and Process experience (internal only)
• Provider payment arrangements (internal Only)
• Clinical coding knowledge of ICD-10 and/or CCSA

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.