Location: Centurion, Gauteng

Position Purpose: To provide expert clinical assessment and decision making in relation to Ex gratia applications, regulatory (CMS) complaints, appeals, disputes and escalations.

Qaulifications& Experience: Registered Nurse with medical diploma/degree and valid SANC registration (MANDATORY REQUIREMENT)

 5 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration      industry or similar.

Solid working experience with the following:

  Appeals and Disputes Management

• Review and assess clinical appeals and disputes in line with scheme rules and clinical guidelines
• Analyse clinical documentation, treatment plans, and provider motivations
• Make evidence-based recommendations on benefit funding and clinical appropriateness
• Ensure turnaround times (TATs) are adhered to

 CMS Case Management

• Manage complaints and escalations received from the Council for Medical Schemes (CMS)
• Compile detailed, accurate, and compliant case responses within required timelines
• Liaise with internal stakeholders to gather relevant clinical and administrative information
• Ensure alignment with the Medical Schemes Act and CMS rulings

 Ex-Gratia Case Review

• Evaluate ex-gratia requests based on clinical merit, financial impact, and member circumstances
• Prepare structured case summaries and recommendations for internal committees
• Ensure decisions are well-motivated, consistent, and documented

 Clinical Assessment & Decision Support

• Interpret clinical data, ICD-10 codes, treatment protocols, and PMB regulations
• Apply managed care principles to ensure cost-effective and appropriate care
• Escalate complex or high-risk cases to senior clinical staff where necessary

Stakeholder Engagement

• Communicate effectively with healthcare providers, members, and internal departments
• Provide clear, professional written responses for disputes and appeals outcomes
• Participate in multidisciplinary discussions and case reviews

 Compliance and Governance

• Ensure all decisions comply with:

• Medical Schemes Act
• Prescribed Minimum Benefits (PMB) regulations
• Scheme rules and policies

• Maintain accurate and auditable records of all cases
• Support internal and external audits

Accountabilities:

 Client service delivery and quality

• Follow procedures and cooperate with peers and leader for best possible service delivery

 Financial Management

• Contribute to cost savings within the department to assist with financial goals and targets.

Operation Model

• Meet delivery objectives through working with other team members within and linked to the department / project

• Resolve operational performance variations and problems and escalate unresolved issues to higher levels

•  Ensure accuracy and quality or clinical reviews and compliance with regulatory and Scheme requirements.

  Evaluate medical records, ICD10 codes, treatment plans and care pathways.

  Review and assess requests for benefits outside the Scheme rules based on clinical necessity, severity and exceptional circumstances and ensure consistency, fairness and ethical decision making.

  Provide clinical input and analysis for responses to CMS complaints, escalations, appeals, disputes and complaints and draft clear accurate feedback.

  Review case histories to identify compliance gaps, clinical risk or opportunities for training and development.

Drive customer-centricity

• Maintain a high level of impact on other departments to support improved delivery – Continually increase understanding of client and stakeholder needs, satisfaction and service delivery

 Maintain expertise level

• Be a member of related professional bodies
• Ensure CPD (continual professional development) or similar accreditation requirements are met annually to ensure maintained specialist accreditation

Operational Implementation of Strategy

• Keep up to date with operational changes implemented in response to important external influences
• Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities
• Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement Operational Leadership
• Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives
• Engage in development, coaching and mentoring
• Support transformation through valuing diversity

Stakeholder Management

• Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved
• Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-i
• Liaise with internal teams, treating providers and external stakeholders where required

 KEY PERFORMANCE AREAS
 

• Logical exploration of problems with innovative solutions.
• Able to work with, and encourage participation in, team efforts.
• Able to handle concurrent tasks.
• Committed to good business ordinance, maintaining an effective internal control environment.
• Able to manipulate data to produce management information.

KEY COMPETENCIES 

Experience

• Compliance and Governance
• Ensure all decisions comply with:
• Medical Schemes Act
• Prescribed Minimum Benefits (PMB) regulations
• Scheme rules and policies
• Maintain accurate and auditable records of all cases
• Support internal and external audits

• Able to communicate effectively with and favourably influence the actions of others not under their control.
• Negotiation Skills and Telephone Etiquette

Knowledge

• Knowledge and application of processes and procedures and the ability to apply excellent reasoning and analytical skills.
• Knowledge and application of relevant legislation and strong understanding of Prescribed Minimum Benefits and Medical Scheme legislation.
• Product and scheme rule knowledge
• Contribute to continuous improvement of clinical review processes and guidelines.

Skills

• Risk awareness, management and mitigation
• Good business ordinance, maintaining an effective internal control environment
• Time management
• Analytical Ability
• Numerical Ability
• Attention to Accuracy and Detail
• Problem Solving
• Customer Focus
• Communication Skills – both written and verbal
• Ability to work independently and manage multiple complex cases
• Ethical reasoning and fairness
• Stakeholder management
• Emotional Intelligence, strong clinical judgment and professionalism
• Analytical and critical thinking

Note: Company reserves the right to close the advert before specified closing date.