CLINICAL ANALYST: CLINICAL CONSULTING

To apply, click on the link at the end of the posts and all the best with your applications

The Council for Medical Schemes is a statutory body established by the Medical Schemes Act (131 of 1998) to provide regulatory supervision of private health financing through medical schemes.
The following position exists for a person driven by the desire to protect the public interest.

The purpose of the job is to provide evidence-based, clinically and financially sound clinical opinions and advice to internal and external stakeholders on clinical health care matters, quality, and cost-effectiveness, and to ensure proper clinical policy. As a Clinical Analyst, you will be responsible for:

▪ Providing clinical opinions in the adjudication of the complaints process.

• Prepare evidence-based clinical opinion responses to complaints in collaboration with internal stakeholders.
• Provide direct responses to clinical enquiries from both internal and external stakeholders within timelines as detailed in
  the Clinical Consulting Unit Standard Operating Procedure (SOP).
  ▪ Collaborating with internal units in the provision of training, information sharing, and publications to
  stakeholders.
• Provide inputs on the Prescribed Minimum Benefit (PMB) training material and support the Education and Training Unit by
  conducting presentations for providers, administrators, schemes, administrative/clinical staff, medical advisors, and other
  identified stakeholders on an ongoing basis.
• Provide clinical-related information and authorship for the preparation of the CMScript, monitor, and apply appropriate
  interventions until resolution.
  ▪ Collaborating with the Policy and Research Unit on the development of PMB definitions and review.
• Provide specialist inputs to the development of PMB definitions and reviews.
• Ensure substantive accuracy in the design and application of proven research methods by demonstrating the application
  of relevant literature-related methods.
  ▪ Providing clinical inputs on scheme rules and other projects.
• Conduct clinical analysis and provide specialist clinical inputs during the review of scheme rules and benefit schedules in
  support of the Benefits Management unit.
• Ensure compliance in the review of benefits and exclusions in relation to the PMB regulations.
• Provide inputs to other projects, including coding, scheme rules, and Managed Care Organisation (MCO) accreditation
  processes, etc.
  ▪ Undertaking assignments/tasks allocated by the line manager in accordance with CMS’ operational requirements.

SKILLS AND KNOWLEDGE BASE
The successful candidate will have the following essential qualifications, competencies, and skills:

• Minimum qualification – Diploma in General Nursing Science, Midwifery, and Psychiatric Nursing at NQF Level 6.
• Minimum of three (3) years’ clinical experience, preferably with ICU/theatre experience.
• Valid registration with the South African Nursing Council.
• Exposure to the medical schemes’ industry or managed health care is essential, and a degree qualification in public health will be an added advantage.
• Proficiency in clinical methodologies, clinical protocol & policy analysis and/or development; and clinical coding (ICD10, CPT, UPFS, Nappi, etc.), preferably intermediate level.
• Understanding of the Medical Schemes Act, the medical schemes industry, and legislation impacting and influencing the functioning of the CMS (MSA, POPIA, PFMA, etc.).
• Understanding of evidence-based medicine principles and ethics in health care, the medical schemes benefit rule design and application.
• Understanding of complaint resolution, critical thinking, problem-solving, and analytical skills.
• Working under pressure, attention to detail, and emotional intelligence.
• Good interpersonal and communication (verbal and written) skills.
• Presentation and report writing skills.
• Computer Literacy.

If you are motivated, tenacious, thorough, detail-oriented, and able to manage multiple projects simultaneously, we invite you to submit your application to recruitment@medicalschemes.co.za. Please indicate the position you are applying for in the subject line. For more information regarding these positions, visit the Council for Medical Schemes’ website:
www.medicalschemes.co.za

Note: Correspondence will be limited to shortlisted candidates only. If you do not hear from us within two (2) months of this advertisement, please accept that your application was unsuccessful. CMS reserves the right to appoint or not to appoint for the above position.

The Council for Medical Schemes is a Designated Employer and is committed to adhering to its Employment Equity Plan and Affirmative Action Measures. Therefore, preference will be given to specific categories of persons.

CLOSING DATE: FRIDAY, 20 MARCH 2026

We wish you all the best with your applications