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Job Description

The primary purpose of the role

The purpose of the job is to oversee the implementation of managed healthcare, which includes integrated care strategy, the implementation of centres of excellence, solutions to identify members at high and severe high risk of illness, home-based care interventions, primary care interventions, GP profiling, and monitor GP and hospital networks.

The ideal candidate will also be required to contribute to the growth and retention strategy by identifying and advising the Scheme appropriately on clinical risk matters and making the necessary recommendations.

Key Responsibilities

As a Clinical Specialist, the ideal candidate will:

Oversee the implementation of the integrated care strategy

  • Monitor whether the agreed phases of the integrated care strategy are met
  • Provide regular reports on support provided and deviations noted

Oversee the implementation of centres of excellence

  • Determine whether the needs of members at high and severe high risk of illness are provided for
  • Monitor the effectiveness of programmes for members at high and severe high risk of illness
  • Advise on the effectiveness of GP networks

Home-based care interventions

  • Monitor the provision of care by day clinics and nursing agencies for minor ailments and surgeries

High-cost procedures and treatments

  • Validate and evaluate requests made for high-cost procedures and treatments
  • Make decisions on such requests and communicate the decisions

Clinical enquiries

  • Investigate matters arising from clinical enquiries and make recommendations
  • Advise the Scheme on clinical matters based on enquiries received
  • Build a network of clinical specialists and form a working group with the administrator’s staff

Clinical Committee

  • Serve in the Clinical Committee, provide input on clinical cases presented, and implement recommendations made by the committee
  • Review high-cost admissions and proposals for new technologies, attend appeal cases, provide clinical input on responses to CMS complaints

Clinical support

  • Participate and support clinical research with a view to make recommendations
  • Liaise with relevant administration staff on clinical recommendations
  • Ensure compliance by the administrator with the Scheme’s clinical policies and protocols
  • Ensure correct application of Prescribed Minimum Benefits by the administrator
  • Create a good understanding via the actuaries on the Scheme’s risk profile
  • Analyse clinical data and use data for service negotiation purposes
  • Contribute to clinical research by participating in projects
  • Stay up to date with changes regarding benefits in the clinical field
  • Liaise with the KeyHealth Enhancement team on the risk profile of the Scheme and make recommendations
  • Support health and safety initiatives within KeyHealth
  • Stay up to date with relevant legislation governing medical schemes and health policy
  • Guide the Scheme on actions to take to adhere to legislation and CMS directives that have a clinical component
  • Evaluate Wellness Days reports received from external service providers

Experience and skills required

The ideal candidate should have

  • A nursing qualification with post-graduate training in epidemiology
  • 5 years’ working experience in a managed healthcare environment of which 3 years must be in evidence-based medicine & clinical management
  • In-depth knowledge and understanding of the clinical environment with an application ability
  • Relevant knowledge and application thereof in the healthcare industry
  • Ability to effectively liaise with external and internal stakeholders
  • Excellent verbal and written communication skills
  • Attention to detail
  • Problem-solving ability
  • Ability to multitask and prioritise work
  • Positive attitude with energy and enthusiasm

How to apply

Submit a cover letter accompanied by a CV to and quote the reference number KH06 07.02.2023 in the subject heading.

If you do not hear from us within 72 hours of the closing date, please consider your application as unsuccessful.

CLOSING DATE: 20 February 2023