Senior Medical Advisor at Discovery Limited

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 Schemes
• Deal 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.

Education and Experience:

The following requirements are essential:

• Matric
• MBBCH
• Registered with the relevant professional body
• At least 2 years clinical experience, post community service
• 2-3 years of managed healthcare experience
• Proven track record of excellence in applying EBM appropriately to Clinically complex cases