Medical Advisor

Position Purpose:As a Medical Advisor, you will be responsible for assessing and making funding decisions on clinically complex cases in line with scheme rules. You will apply evidence based medicine principles, ensure clinical governance, support operational teams, and engage with external healthcare providers to promote high quality and cost effective care.

This role also contributes to clinical leadership, training, and process improvement across the managed care environment.

• MBChB or equivalent medical qualification
• Full and current HPCSA registration - Independent Practice
• Minimum 2 years' experience in a private hospital or clinic
• Solid understanding of Prescribed Minimum Benefits (PMBs)

• Previous managed healthcare or Medical Advisor experience
• Clinical coding knowledge (ICD 10)

• Clinical Support & Advisory Services: Provide expert clinical input across multiple managed care functions, conduct daily clinical reviews, and ensure all funding decisions are defensible, evidence based, and aligned with scheme rules.
• Participation in Clinical Governance Forums: Actively contribute to internal and external committees, including Managed Care Committees, PMB Review Panels, Ex Gratia Committees, and High Cost Case Review meetings.
• Stakeholder & Provider Engagement: Build and maintain strong working relationships with healthcare providers and offer expert clinical input during monthly client forums.
• Claims Management & Coding Support: Assist in reviewing pathology, radiology, and PMB related claims, support tariff file accuracy, and resolve complex claim related queries.
• Compliance, Legislation & Industry Awareness: Stay updated on regulatory and clinical industry developments and incorporate new insights into clinical decisions.
• Knowledge & Data Management: Maintain accurate clinical records, knowledge repositories, and decision logs to ensure complete, traceable, and audit ready documentation.
• Ensures accountability
• Action oriented with strong decision making skills
• Manages ambiguity and complexity effectively
• Strong communication and stakeholder management
• Strategic mindset with business insight
• Resourceful, resilient, and self aware

PHA is an Equal Opportunity Employer. Employment Equity principles will be applied during the recruitment process. We actively encourage persons with disabilities to apply.

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

PHA has its head office in Westville, KwaZulu Natal. It operates country wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.