Medical Case Manager jobs

Introduction

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organizations’ care for and reward their employees and members.

Disclaimer

As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose

Managing the delivery of clinical input across the business unit. Overseeing the effective application of evidence based medicine and risk management principles.

Requirements

• Matric
• MBChB or Fam Med qualification
• Previous medical advisory experience will be an advantage
• Registered Medical Practitioner (MBChB or equivalent qualification) with the Health Professions Council of South Africa (HPCSA).
• 5-8 years' post-community service clinical experience as a Medical Doctor.
• 3-5 years' experience in a managed healthcare, medical scheme, healthcare funding, or medical aid administration environment.
• Experience in the clinical assessment of:
  • Hospital admissions and pre-authorisations.
  • Prescribed Minimum Benefits (PMBs).
  • Chronic Disease Management.
  • High-cost and specialised treatment funding requests.
• Experience interpreting and applying clinical protocols, treatment guidelines, and evidence-based medicine principles.
• Experience providing clinical support and advice on medical aid benefit decisions and funding determinations.
• Sound knowledge of the Medical Schemes Act, PMB Regulations, and Council for Medical Schemes (CMS) requirements.

Duties & Responsibilities

PROCESS

• Medical Advisory work, as directed by the Health Risk Management and Client Execution.
• Managing the delivery of clinical input across the business unit.
• Overseeing the effective application of the Health Risk Management clinical policies and protocols across the business unit.
• Training of case managers, pharmacists and/or pharmacist assistants in case forums.
• Attendance of Medical Advisors meetings.
• Relevant work to be done with reference to medical scheme rules and within the parameters of relevant coding rules and Evidence Based Medicine.
• Supporting the development of guidelines and protocols for the Health Risk Management according to the standards prescribed by the Head of Clinical Policy.
• Review of the pathology, radiology and Prescribed Minimum Benefit (PMB) claims and maintenance of the tariff files in conjunction with the coding team.
• Provision of clinical input and presentation of exgratia cases on a monthly basis at client Clinical forums.
• Generation and analysis of product specific reports on a monthly basis.
• Management of the benefit design requirements for identified schemes as it relates to clinical input.

CLIENT

• Build and maintain relationships with clients and stakeholders that promote cross delivery practice solutions.
• Contribute to sustaining a competitive edge through external networking and benchmarking and representation on related forums.
• Define fair and innovative client service practices which build rewarding relationships, and allows team to provide exceptional client service.
• Engage with key internal and external stakeholders to identify changing client needs and make recommendations to align service offering with client needs.
• Manage a client service excellence culture which builds enduring relationships and allows team to provide exceptional client service.
• Manage the introduction of new channels for client interaction in order to improve client services against service expectations.

PEOPLE

• Be a member of and make positive contributions to Professional Bodies and Stakeholder Groups.
• Create a positive work climate and culture to energise employees, give meaning to work, minimise work disruption and maximise employee productivity.
• Develop, implement and manage a People Capability plan that ensures that the function has the human resources and skills required to deliver on the strategy for the short, medium and longterm.
• Identify, attract, appoint, grow, engage, reward and retain top talent to drive strategic execution.
• Demonstrate exemplary leadership behaviour, through personal involvement, commitment and dedication in support of organisational values.
• Drive a culture that guides and directs best practice, fostering an environment of continuous learning, improvement and cohesiveness.
• Enable a learning and growth culture whereby information regarding successes, issues, trends and ideas are actively shared between team members.
• Identify employee growth and development needs and schedule interventions to enable ongoing development, training and personal growth.
• Effectively manage performance within the team in order to ensure business objectives are achieved.
• Ensure that employees are effectively recognised and rewarded in line with organisational practice and governance set by the REM committee.
• Encourage innovation, change agility and collaboration within the team.

FINANCE

• Implement and compile budgets to minimise expenditure in alignment with tactical delivery plans.
• Control the budget for area, including the authorisation of expenditures and implementation of financial regulations.
• Manage high risk and problematic financial issues in area of accountability and contribute to the development of policy.
• Implement and manage financial risk methodologies, techniques and systems and use to monitor and report on financial activities.
• Implement and provide feedback on the effectiveness of financial policy, practice and procedures: preventing illegal, unethical or improper conduct.
• Implement risk management, governance and compliance policies in own practice area, to identify and manage governance and risk exposure liability.
• Investigate reported wilful acts of noncompliance to organisation policy and practice and report on finding.

Competencies

• Examining Information
• Interpreting Data
• Providing Insights
• Generating Ideas
• Making Decisions
• Checking Things
• Managing Tasks
• Taking Action