Doctor-Non-Disclosure & Underwriting at Discovery Limited

Key Purpose:

This position requires the successful candidate to be able to make clinical decisions linked to the assessment of non-disclosure, in addition lead policy changes, protocol enhancements, applying appropriate clinical and medicine-based knowledge and experience in determining material non-disclosure.

Key Outputs:

• The successful applicant will be responsible for but not limited to the following job functions:
• Lead policy enhancements for the NDC environment 
• Dealing with escalations and managing doctor to doctor calls
• Managing the appeals process and dealing with the members appeals directly 
• Provide clinical support to the Underwriting, Non-disclosure and Informa teams, as well as other business areas
• Provide steer and make decisions on complex cases
• Participating in key clinical forums internally and externally
• Preparing of cases, case presentation, loading member remarks and exceptions
• Coaching with clinical intervention 
• Clinical case studies – cases related to symptom and diagnosis 
• Writing protocols with support from CAS and other clinical environments 
• Communication of decisions to the relevant parties
• Review of clinical evidence on a case-by-case basis
• Identify operational gaps and initiate improvement strategies
• Maintenance of database of decisions made
• Identifying high-cost conditions where we find non-disclosure  
• Representing teams in forums; BCR, Risk Exco, Underwriting Steercom, Clinical Review
• Keeping abreast with legislative and industry changes and how it affects your business unit
• Identification of new trends in Medical Industry, and engagement with relevant clinical stakeholders
• Constant interaction and relationship building with external health care providers
• Provide support to the Benefit Compliance Review team
• Provide support to the executive executive office team
• Competencies and Personal Attributes:
• Resilience - the ability to respond to, and recover quickly from, difficulties in the workplace to ensure you’re always persevering with a ‘never give up’ attitude." Perseveres through adversity and recovering quickly from setbacks.
• Adapts to changing circumstances - accepts new ideas and change initiatives. Adapts interpersonal style to suit different people or situations. Shows respect and sensitivity towards cultural and religious differences. Deals with ambiguity, making positive use of the opportunities it presents.
• Works productively in a high-pressure environment - keeps emotions under control during difficult situations. Balances the demands of a work life and a personal life. Maintains a positive outlook at work. Handles criticism well and learns from it.
• Analyses numerical data, verbal data and all other sources of information - breaks information into component parts, patterns and relationships. Probes for further information or greater understanding of a problem. Makes rational judgments from the available information and analysis. Produces workable solutions to a range of problems. Demonstrates an understanding of how one issue may be a part of a much larger system. 
• Deciding and Initiating Action - makes prompt, clear decisions, which may involve tough choices or considered risks. Takes responsibility for actions, projects and people. Takes initiative, acts with confidence and works under own direction. Initiates and generates activity
• Following Instructions and Procedures - appropriately follows instructions from others without unnecessarily challenging authority. Follows procedures and policies. Keeps to schedules. Arrives punctually for work and meetings. Demonstrates commitment to the organization. Complies with legal obligations and safety requirements of the role. 
• Presenting and Communicating Information - speaks clearly and fluently. Expresses opinions, information and key points of an argument clearly. Makes presentations and undertakes public speaking with skill and confidence. Responds quickly to the needs of an audience and to their reactions and feedback. Projects credibility. 
• Delivering Results and meeting customer expectations - focuses on customer needs and satisfaction. Sets high standards for quality and quantity. Monitors and maintains quality and productivity. Works in a systematic, methodical and orderly way. Consistently achieves project goals. 
• Problem Solving - uses rigorous logic and methods to solve difficult problems with effective solutions; probes all fruitful sources for answers; can see hidden problems; is excellent at honest analysis; looks beyond the obvious and doesn't stop at the first answers.
• Adapts to changing circumstances - accepts new ideas and change initiatives. Adapts interpersonal style to suit different people or situations. Shows respect and sensitivity towards cultural and religious differences. Deals with ambiguity, making positive use of the opportunities it presents.
• Works productively in a high-pressure environment - keeps emotions under control during difficult situations. Balances the demands of a work life and a personal life. Maintains a positive outlook at work. Handles criticism well and learns from it.
• Accepts and tackles demanding goals with enthusiasm - works hard and puts in longer hours when it is necessary. Identifies development strategies needed to achieve career goals and makes use of developmental or training opportunities. Seeks progression to roles of increased responsibility and influence

Skills:

• Learning on the Fly: Learns quickly when facing new problems; a relentless and versatile learner; open to change; analyzes both successes and failures for clues to improvement; experiments and will try anything to find solutions; enjoys the challenge of unfamiliar tasks; quickly grasps the essence and the underlying structure of anything. 
• Priority Setting: Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus. 
• Conflict Management: Steps up to conflicts, seeing them as opportunities; reads situations quickly; good at focused listening; can hammer out tough agreements and settle disputes equitably; can find common ground and get cooperation with minimum noise. 
• Interpersonally Savvy: Relates well to all kinds of people—up, down, and sideways, inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can defuse even high-tension situations comfortably.
• Peer Relationships: Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers. 
• Dealing with Paradox: Can act in ways that seem contradictory; is very flexible and adaptable when facing tough calls; can combine seeming opposites like being compassionately tough, stand up for self without trampling others, set strong but flexible standards; can act differently depending upon the situation; is seen as balanced despite the conflicting demands of the situation. 

Qualifications & Experience: 

The following are essential criteria for the position

• Qualified Medical Doctor
• Full and Current HPCSA registration - Independent Practice
• Minimum of two years experience in a Private hospital or clinic 
• Thorough knowledge of Medical Insurance Law
• Ability to communicate on a high, technical level (e.g. with actuaries).
• Knowledge of Managed Care Environment
• Sound knowledge of Prescribed Minimum Benefits
• Excellent written and verbal communication skills in English
•    Proficient with the following computer packages:

Excellent Excel skills

• PowerPoint
• Outlook
• Knowledge of Discovery system such as paradigm and pinpoint
• The following are advantageous criteria for the position
• Knowledge of Discovery Health Medical Scheme and In-House products