Senior Medical Advisor - SandtonFull job descriptionBusiness Unit: Discovery HealthFunction: ClinicalDate: 9 May 2024Discovery Care Senior Medical Advisor – Gauteng 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 Discovery Care Discovery Care is a subsidiary for Discovery Health - made up of 8 distinct areas with segmented teams responsible for the processing of specialized claims, CIB queries and escalated clinical queries processes while our case management teams are responsible for reviewing clinical cases for each of the specialized areas. Our clinical services area is also responsible for all council disputes while our high touch team provide hands on services and escalated query resolution to sensitive cases. Key Purpose: The incumbent’s role is to be the central clinical support within the Benefit Compliance Review (BCR) team including Council for Medical Schemes complaints and disputes, as well as the Ex Gratia team. Key Purpose: The successful applicant will be responsible for but not limited to the following job functions: Provides clinical support in preparing and presenting all disputes (rule 27) and compiling of responses to the Council for Medical Schemes, including vetting of letters in order to ensure quality of output and service delivery.Source all the relevant clinical evidence pertinent to each case and obtain input from relevant external experts proactively when required.Liaise with the treating doctor and other relevant medical providers.Develop sound working relationships with CCE, Risk and other relevant internal stakeholders and involve these areas in member specific decisions; use these inputs to inform and enhance processes and benefits.Provide clinical upskilling to all BCR colleagues on identified clinical topics.Assist Clinical and non-clinical staff with guidance and input where required.Provide feedback on Ex-Gratia Cases at the Clinical Governance Forum.Support the Legal Advisors with the Bi-weekly Dispute Committee meeting and to provide all relevant clinical information related to the case.Guide the Legal Advisors when preparing Heads of Argument for the Council of Medical SchemesDeal with complaint escalations by doing a thorough investigation of the case and providing recommendations to the Schemes by writing a formal response on behalf of the Administrator.Present all Ex-Gratia cases and recommendations to the Executive Committee Review team on an ad-hoc basis or via email round robin in order to obtain a favourable outcome for the individual as well as the greater membership of the Scheme.Build and maintain effective working relationships with internal and external stakeholders such as the Council for Medical Schemes, DHMS as well as all in house schemes administered by Discovery Health, their Fund Managers and Principal Officers.Play an integral role in various internal steer committees such as Prescribed Minimum Benefits, Underwriting, Health Partners, and Forensics in order to make the necessary improvements and proactively avoid complaints or disputes.In conjunction with the CCE unit, develop guiding principles based on the rulings made by the Council for Medical Schemes and communicate these to all relevant stakeholders.Participate in business continuous improvement initiatives arising from Disputes and CoMS complaints e.g. at PMB forum.Attend In House Ex-Gratia committee meetings as required to provide relevant clinical input. Competencies: The successful candidate must demonstrate the following competencies: Role Specific BehavioursEnsures accountability.Action orientedManages ambiguity.Attracts top talent.Business insightCollaboratesCommunicates effectively.Manages complexity.Manages conflict.CourageCustomer focusDecision qualityDevelops talent Values differencesDirects work.Drives engagementFinancial acumenGlobal perspectiveCultivates innovation.Interpersonal savvyBuilds networks.Nimble learningOrganizational savvyPersuadesPlans and aligns.Being resilient ResourcefulnessDrives resultsDemonstrates self-awareness.Self-developmentSituational adaptabilityBalances stakeholdersStrategic mindsetBuilds effective teams.Tech savvyInstils trust.Drives vision and purposeOptimizes work processes Education and Experience: The following requirements are essential:MatricMBBCHRegistered with the relevant professional bodyAt least 2 years clinical experience, post community service2-3 years of managed healthcare experienceProven track record of excellence in applying EBM appropriately to Clinically complex cases The following requirements will be advantageous:Health Economics and or law related qualification and/or experience Personal Attributes or Competency Profile The Discovery Person Values DrivenOptimisticLearns on the FlyResilientInstils TrustPeople SavvyDrives ResultsProblem SolverEMPLOYMENT EQUITYThe 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.
