Specialist Clinical Policy

Position Purpose:Policy Specialist: contributes to the development, maintenance, and continuous improvement of evidence based clinical policies, coverage criteria, and benefit rules across the organization. The role provides clinical and analytical support to ensure policy decisions are grounded in high quality evidence, compliant with statutory requirements, operationally implementable, and aligned with the organization's Health Risk Management strategy. The position works closely with HTA Specialists and policy pharmacists to support policy formulation and implementation.

• A health sciences degree (Medicine - MBBCh/MBChB), BSc, or related field).
• Postgraduate qualification in Public Health, Health Economics, Epidemiology, Clinical Research, or Health Policy (preferred).
• 1-2 years in clinical policy, managed care, HTA, Research, clinical governance, or similar 1environments.
• Experience drafting or implementing clinical policies or protocols.
• Experience in medical schemes or health insurance regulatory environments. (Advantageous)

• Support the development, review, and maintenance of clinical policies, protocols, and benefit criteria.
• Ensure policy recommendations are based on strong evidence, guidelines, utilisation trends, and clinical context.
• Contribute to policy lifecycle activities: intake, consultation, approval, implementation, and review.
• Draft policy documents, benefit criteria, and operational decision pathways.
• Translate HTA findings into policy recommendations and benefit guidelines.
• Assist with reviewing HTA dossiers, rapid reviews, and horizon scanning outputs.
• Ensure policies comply with legislative requirements, including PMB standards.
• Interpret regulatory updates and support necessary process or policy changes.
• Contribute to regulatory audits, appeals, and compliance reviews.
• Assess coding implications (ICD 10, CPT, ATC) for accurate claims adjudication.
• Prepare documentation for governance committees and participate in multidisciplinary discussions.
• Provide clinical and policy guidance to internal teams and support complex clinical queries.
• Monitor policy KPIs and analyse appeals, utilisation trends, or provider patterns for refinement opportunities.
• Support continuous improvement of policy frameworks and evidence standards
• Evidence appraisal and guideline interpretation.
• Knowledge of PMB standards, benefit design, and managed care concepts.
• Understanding of coding systems (ICD 10, CPT, ATC).
• Ability to translate evidence into operational policy requirements.
• Strong analytical, writing, and presentation skills.
• Strategic thinking
• Communication
• Resilience
• Technical/organisational savvy

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.