Legal and Compliance Advisor

The Legal and Compliance Advisor will provide strategic legal, regulatory, and compliance support across the Medical Advisory Unit (MAU), Health Policy Unit (HPU), and the broader administrator. The role will ensure regulatory alignment, strengthen governance and control, mitigate legal and compliance risk, and enhance member confidence through authoritative legal interpretation, effective dispute resolution, and strong compliance oversight.

In addition, the role will support the broader PHA administrator by providing legal input on documentation, improving clarity in member-facing and operational communications, and contributing to member engagement processes where legal accuracy, regulatory compliance, and reputational risk management are essential.

• At least 3-4 years of working experience in the medical schemes or CMS environment
• Knowledge of the managed care environment
• Excellent written and verbal communication skills in English
• Proficiency in Microsoft Office, with strong Excel capability
• Experience drafting legal documents, including Heads of Argument, legal opinions, and legal letters

• Represent Schemes in Dispute Hearings and manage the end-to-end dispute resolution process.
• Draft, review, and respond to legal letters of demand and other legal correspondence.
• Provide legal support and advice in relation to appeals submitted to the CMS.
• Deliver legal and compliance training to the Appeals and Disputes Team to strengthen capability and consistency in case handling.
• Monitor CMS rulings, legal precedents, and industry developments to inform decision-making and risk mitigation.
• Draft heads of argument, submissions, legal opinions, and supporting documentation for disputes and appeals.
• Maintain compliant record keeping, governance documentation, and reporting standards within the unit.

• Ensure managed care policies, protocols, and operational frameworks comply with relevant legislation, regulations, and CMS requirements.
• Review benefit design structures, provider contracts, funding arrangements, and utilisation management policies from a legal and compliance perspective.
• Provide legal input on matters involving provider associations, stakeholder concerns, and patient advocacy issues.
• Design and strengthen compliance monitoring systems for protocols, contractual obligations, reimbursement models, and governance processes.
• Advise on litigation and regulatory risks arising from member complaints, benefit access disputes, and policy interpretation.
• Support clinical and governance committees with legal, compliance, and risk management input.
• Liaise with regulators and relevant stakeholders to ensure accurate, timely, and compliant reporting.
• Educate and guide staff on compliance obligations, fraud prevention, ethical conduct, and legal risk awareness.

• Review and refine member-facing communication to ensure legal accuracy, clarity, and compliance with scheme rules, legislation, and regulatory requirements.
• Support the business in developing clear, compliant communication on complex benefits, plan types, member matters, complaints, escalations, and high-risk correspondence.
• Contribute to member engagement processes by ensuring communications and interventions are legally sound, consistent, fair, transparent, and member centred.
• Provide legal interpretation and advisory support to business units on the Medical Schemes Act, scheme rules, administrator agreements, provider agreements, claims adjudication, funding protocols, and provider billing practices.
• Strengthen member trust and organisational credibility through legally robust communication practices and effective compliance with healthcare laws, regulations, standards, and Service Level Agreements.
• Provide specialised legal, litigation, and regulatory support in the management of fraud, waste, and abuse (FWA).
• Ensure compliance with relevant legislation and evidentiary standards, including PAJA and POPIA, to enable effective investigation, recovery, and enforcement action.
• Provide legal guidance across the full lifecycle of FWA investigations, including review of forensic reports and recommendations on civil, criminal, and contractual remedies.
• Manage litigation and dispute processes relating to provider recoveries, member fraud, contractual disputes, settlement negotiations, and debt recovery frameworks.
• Liaise with external legal counsel, SAPS, prosecuting authorities, regulators, and professional bodies.
• Ensure compliance with healthcare laws, regulations, and standards, including monitoring and enforcing adherence to Service Level Agreements (SLAs).