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.

Experience: 2-5 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

  Qualifications: Registered Nurse or Enrolled Nurse (Preferred) – Registered with SANC or

Industry related qualification.

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
• 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-in
• 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.