Doctor - Discovery Limited

This position requires the successful candidate to be able to make funding decisions for clinically complex cases as per scheme rules, in keeping with principles of evidence-based medicine while promoting cost-effective and quality healthcare for our members and managing interactions with external clinical providers.

Key Outputs:

The successful applicant will be responsible for but not limited to the following job functions:

• Provide clinical support to the Medical Review team, PMB team, Chronic Illness Benefit, hospital case management, oncology case management, exec office, benefit compliance review, the underwriting and forensics area, as well as other business areas.
• Ensuring the workflow pools and TWT are met
• Participating in key clinical forums internally and externally
• Daily Clinical Review – Preparing of cases, case presentation, loading member remarks and clinical exceptions arranging second opinions/external expert opinions and follow up
• Communication of funding decisions to the relevant parties
• Keeping abreast with legislative and industry changes and how it affects your business unit
• Keeping updated with the latest clinical thinking and attending CPD events
• Identification of new trends in the Medical Industry, and engagement with relevant clinical stakeholders
• Constant interaction and relationship-building with external healthcare providers
• Maintenance of the database of funding decisions made
• Support to Junior Staff and other Medical Advisors
• Knowledge of Claims, coding and assisting in getting payment resolutions
• Identify operational gaps and initiate improvement strategies
• Clear knowledge of evidence-based medicine and the application thereof
• Review of clinical evidence on a case-by-case basis
• Liaison with various business group TWGs

Competencies:

• Analyzing: Analyses numerical data, verbal data and all other sources of information. Breaks information into component parts, patterns and relationships. Probes for further information or greater understanding of a problem. Makes rational judgments from the available information and analysis. Produces workable solutions to a range of problems. Demonstrates an understanding of how one issue may be a part of a much larger system.
• Deciding and Initiating Action: Makes prompt, clear decisions, which may involve tough choices or considered risks. Takes responsibility for actions, projects and people. Takes initiative, acts with confidence and works under own direction. Initiates and generates activity
• Following Instructions and Procedures: Appropriately follows instructions from others without unnecessarily challenging authority. Follows procedures and policies. Keeps to schedules. Arrives punctually for work and meetings. Demonstrates commitment to the organization. Complies with legal obligations and safety requirements of the role.
• Presenting and Communicating Information: Speaks clearly and fluently. Expresses opinions, information and key points of an argument clearly. Makes presentations and undertakes public speaking with skill and confidence. Responds quickly to the needs of an audience and to their reactions and feedback. Projects credibility.
• Delivering Results and meeting customer expectations: Focuses on customer needs and satisfaction. Sets high standards for quality and quantity. Monitors and maintains quality and productivity. Works in a systematic, methodical and orderly way. Consistently achieves project goals.
• Problem-Solving: Uses rigorous logic and methods to solve difficult problems with effective solutions; probes all fruitful sources for answers; can see hidden problems; is excellent at honest analysis; looks beyond the obvious and doesn't stop at the first answers.

Skills:

• Learning on the Fly: Learns quickly when facing new problems; a relentless and versatile learner; open to change; analyzes both successes and failures for clues to improvement; experiments and will try anything to find solutions; enjoys the challenge of unfamiliar tasks; quickly grasps the essence and the underlying structure of anything.
• Priority Setting: Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.
• Conflict Management: Steps up to conflicts, seeing them as opportunities; reads situations quickly; good at focused listening; can hammer out tough agreements and settle disputes equitably; can find common ground and get cooperation with minimum noise.
• Interpersonally Savvy: Relates well to all kinds of people—up, down, and sideways, inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can defuse even high-tension situations comfortably.
• Peer Relationships: Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers.
• Dealing with Paradox: Can act in ways that seem contradictory; is very flexible and adaptable when facing tough calls; can combine seeming opposites like being compassionately tough, stand up for self without trampling others, set strong but flexible standards; can act differently depending upon the situation; is seen as balanced despite the conflicting demands of the situation.

Qualifications & Experience:

The following requirements are essential:

Matric

• Qualified Medical Doctor
• Full and Current HPCSA registration - Independent Practice
• Minimum of two years experience in a Private hospital or clinic

Knowledge & Skills:

Knowledge of Managed Care Environment

• Sound knowledge of Prescribed Minimum Benefits
• Excellent written and verbal communication skills in English
• Basic computer Literacy in Microsoft Office applications (must be proficient in Excel)

Advantageous:

• Knowledge of Discovery Health Medical Scheme and In-House products