Dental Advisor at Momentum Metropolitan Holdings Limited

Role Purpose    

• The purpose of the Dental Advisor role is to provide expert clinical and technical dental input across Health Risk Management Strategy and operations, ensuring high-quality, evidence-based decision-making on complex, escalated, and exceptional dental cases.
• The Dental Advisor supports the Head of Dental Strategy with clinical input into dental system design, benefit innovation, and the ongoing optimisation of dental risk management frameworks.
• The role serves as the dental clinical Subject Matter Expert (SME), supporting operational teams through specialist case input, dental coding expertise, and fraud, waste and abuse (FWA) investigations.
• In addition, the Dental Advisor provides independent clinical oversight across dental claims, pre-authorisations, benefit interpretation, and provider behaviour, ensuring clinical appropriateness, regulatory compliance (including CMS and PMB requirements), member fairness, and scheme sustainability.
• The role acts as a key clinical governance safeguard between policy intent, operational execution, and system rule application.

Requirements    

• Matric.
• BChD / BDS or equivalent dental qualification.
• Registered with the HPCSA as a Dental Practitioner.
• Dental advisory experience within a managed care or medical scheme environment.
• Strong working knowledge of dental coding (mandatory).
• Experience providing clinical input on complex, escalated, or exception dental cases.
• Experience in fraud, waste and abuse investigation and advisory support (advantageous).

Duties & Responsibilities    

Clinical Governance and Compliance:

• Apply CMS regulations, PMB rules, and scheme policies to dental cases and benefit interpretation.
• Ensure evidence-based, defensible, and audit-ready clinical decision-making.
• Support responses to CMS, SADA, DENTASA, internal audit, and regulatory queries where dental clinical input is required.x
• Claims and Pre-Authorisation Oversight:
• Clinically review high-cost, in-hospital, PMB, and escalated dental claims.
• Provide clinical recommendations on approvals, rejections, and appeals.
• Guide Operations on complex clinical escalations and interpretation of dental clinical policy.
• Benefit Design and Product Support:
• Provide clinical input into dental benefit design, annual reviews, and benefit optimisation initiatives.
• Assess clinical relevance and risk impact of new dental and laboratory codes.
• Advise on exclusions, limits, frequencies, and clinical eligibility criteria.
• Provider and Network Advisory:
• Identify abnormal or high-risk provider claiming patterns.
• Support provider education, remediation, and fraud, waste and abuse investigations.
• Provide clinical input into network rules and provider credentialing criteria.
• System and Rule Enablement:
• Translate dental clinical policy into system adjudication logic.
• Validate clinical rules including tooth numbering, age limits, procedure combinations, and ICD-10 alignment.
• Participate in UAT and provide clinical sign-off for dental-related system and rule changes.

Competencies    

• Business Acumen.
• Client/ Stakeholder Commitment.
• Drive for Results.
• Impact and Influence.
• Collaboration.

Closing Date    

• 2026/03/12