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Pretoria: Medical Advisor

Pretoria: Medical Advisor

Posted on 2025-07-04 00:00:00

Employer Unspecified
Category Healthcare / nursing
Location Tshwane  / Pretoria

Job Summary

PLEASE NOTE THAT NO CV WILL BE KEPT FOR FUTURE USE. IF YOU DO NOT GET FEEDBACK WITHIN 3 WEEKS PLEASE SEE YOUR APPLICATIONS AS UNSUCCESSFUL A COVERING LETTER MUST BE ADDED TO APPLICATION WITH THE VALUE THAT YOU CAN ADD AND WHY YOU ARE APPLYING. MBChB. Valid registration with HPCSA. Additional post graduate certifications. The successful candidate will be responsible for but not limited to the following functions: · Provide clinical support to the Clinical Committee, Executives and Schemes management with escalations and/or complaints, as well as the various clinical teams in pre-authorisation, hospital case management, clinical audit, active disease and chronic risk management, oncology case management, pharmaceutical benefit management and spinal programme management. Ensuring the medical advisory workflows are attended to and the turn-around times are met. Review of clinical evidence on a case-by-case basis. Daily Clinical Review which includes the preparation of cases and case presentation of clinical exceptions and/or high cost/ high risk cases, the arranging of second opinions and follow-up. Succinct communication of funding decisions to the relevant parties (healthcare provider, member, broker and other stakeholders) telephonically and in writing. Actively participating in key clinical forums/ committees both internally and externally. Supporting clinical staff and other Medical Advisors. Building and maintaining mutually beneficial relationships with external health care providers. Knowledge of various healthcare industry coding and claims structures and assisting to achieve payment resolutions. Identify and communicate operational challenges that are impacting the delivery of the managed healthcare services and participate in improvement strategies. Staying up to date with legislative and industry changes and how it may affect the various managed care services Identification of new trends in the medical industry, and engagement with relevant clinical and funding stakeholders pertaining to the potential impact thereof. Keeping updated with the latest clinical trends, new medical technologies and attending CPD events. Experience within Medical Scheme and/ or managed healthcare environment (3 5 years) Knowledgeable of the Medical Schemes Act, PMB legislation and various Council for Medical Scheme Scripts and Publications. In-depth knowledge and understanding of all industry coding and fee structures ICD10, CPT, RPL, SAMA Billing Guide, global fees, per diem, etc. Practical clinical experience in a private hospital or clinic performing and/ or assisting with surgical procedures. Experience in protocol, funding guideline and treatment basket development and implementation. Health economics understanding.

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Pretoria: Medical Advisor

Pretoria: Medical Advisor

Posted on 2025-07-03 00:00:00

Employer Unspecified
Category Healthcare / nursing
Location Tshwane  / Pretoria

Job Summary

Exciting Opportunity: Medical Advisor Location: On-site Contract Type: Full-time Our client, a leading healthcare services provider, is seeking a qualified and experienced Medical Advisor to join their dynamic team. This is a key clinical and advisory role that supports accredited managed healthcare services by ensuring compliance with the Medical Schemes Act, Council for Medical Schemes (CMS) guidelines, legislative requirements, and funding protocols. Key Purpose of the Role The Medical Advisor will make clinically sound and cost-effective funding decisions on complex medical cases, guided by evidence-based medicine and treatment protocols. The ideal candidate will act as a trusted advisor – collaborating with internal clinical teams and external healthcare providers – ensuring quality care delivery and adherence to scheme rules. Minimum Requirements MBChB degree Valid HPCSA registration 35 years experience in a medical scheme or managed healthcare environment Additional postgraduate certifications (advantageous) Key Responsibilities Provide expert clinical input across pre-authorisation, hospital case management, audits, chronic disease and oncology management, pharmaceutical benefits, and spinal programme services Evaluate clinical evidence and high cost/risk cases with clear, timely funding decisions Communicate decisions effectively with stakeholders (providers, members, brokers) Support the Clinical Committee and executive leadership with escalated cases Contribute to protocol and treatment basket development Participate in clinical forums and build strong provider relationships Stay informed on industry coding (ICD10, CPT, RPL), CMS publications, and claims structures Identify healthcare trends, advise on innovation, and support operational improvements Assist in resolving coding, billing, and claims-related issues Share clinical guidance across internal business units Key Skills & Competencies In-depth knowledge of the Medical Schemes Act, PMBs, and health industry metrics Experience in clinical practice (preferably private hospital/clinic setting) Strong verbal and written communication skills High level of accountability and decision-making ability Collaborative, adaptable, and tech-savvy Customer-focused with strong business insight Skilled in conflict resolution and influencing stakeholders Proficient in Microsoft Office and healthcare systems Application Requirements To apply, please submit the following: A compelling cover letter outlining your motivation and the value you bring Certified copy of your HPCSA registration Abridged Curriculum Vitae (CV) If you’re passionate about advancing evidence-based healthcare and influencing clinical decisions at a systemic level, we invite you to apply for this impactful role. Apply now and help shape the future of managed healthcare.

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