Senior Manager: Medical Advisory Services at Government Employees Medical Scheme RSA

The position of Senior Manager: Medical Advisory Services is vacant. The Senior Manager: Medical Advisory Services will report directly to the Chief Healthcare Officer and form part of the Healthcare Management division. The position is based at Head Office, Pretoria.

 The total remuneration package will be based on qualifications and experience.

 The Senior Manager: Medical Advisory Services will be required to support the Chief Healthcare Officer through the implementation of the following Key Performance Areas (KPAs):

• Assist the Chief Healthcare Officer in executing all clinical and medical advisory services within the Healthcare Management division and maintain clinical oversight on all aspects of the Scheme’s business.
• Ensure that the execution of clinical and medical advisory services within GEMS are sound and in compliance with the Medical Schemes Act and Regulations and the Scheme Rules.
• Conduct systemic reviews of evidence-based clinical practice guidelines and ensuring that Scheme funding decisions are based on best practice.
• Manage the activities of the Scheme’s Expert Advisory Panels that assist in maintaining the Scheme's evidence-based clinical protocols.
• Timeously review and make funding decisions and/or recommendations on the Scheme’s Ex Gratia ratification cases using evidence-based medicine.
• Manage and maintain the Scheme’s Ex Gratia guidelines.
• Provide clinical expertise and support to the Scheme’s Ex Gratia Committee and Sub-Committee.
• Oversee the Scheme’s Maternity Programme and ensure strategic objectives are achieved.
• Oversee the Pathology & Radiology Benefits Management, including, but not limited to, claims management and clinical review of billing rules and tariff files.
• Establish new alternative re-imbursement arrangements (ARMs) and value-based reimbursement arrangements in maternity, pathology, radiology, and high-cost medicines/biologics.
• Review and ensure CMS circulars are responded to and timeously implemented.
• Review and provide written responses on the clinical aspects of all CMS complaints, appeals, and all other complaints timeously.
• Attend and participate in various Scheme Forums and make valuable contributions by providing the expertise needed to provide strategic and clinical advisory services.
• Provide clinical expertise and support to the Scheme’s Divisions, as well as business units within the Healthcare Management division.
• Represent the Scheme and actively participate in all external stakeholder forums, conferences, etc.
• Support the Scheme’s strategic objectives and mandates. This includes elements of innovation that are key to the Scheme’s objectives.

Qualification requirements are:

• MBCHB as a minimum qualification. Must be registered with the Health Professions Council of South Africa (HPCSA).
• Minimum 5 years of work experience in the medical aid/managed care industry.
• Minimum 4 years as Manager / Senior Manager in the managed care/ medical aid industry.
• Experience in Clinical and Financial Risk Management.
• Benefit Design Experience.
• Must be in possession of a valid driver’s license and own vehicle and be willing to travel at short notice.
• A good understanding of all coding (Nappi, Tariffs, ICD10, CPT4, UPFS, and more).
• The ability to conduct research using a variety of academic and market-related resources.
• Essential skills:
  • Have a good understanding of GEMS Rules, Benefit Design, as well as administrative and managed care protocols;
  • Have a good understanding of the South African healthcare industry, the Medical Schemes Act, and other legislation;
  • Be organised and have good time management skills;
  • Be analytical and have the ability to manage priorities;
  • Have excellent written and verbal communication skills;
  • Have good interpersonal skills;
  • Have the ability to work well as part of a team;
  • Be computer literate on advanced levels;
  • Be responsible and reliable;
  • Have a diligent work ethic with attention to detail;
  • Be self-motivated and pro-active;
  • Have strong negotiation skills;
  • Work well under pressure.