CLINICAL ANALYST: MANAGED CARE ORGANISATIONS (MCO) – 20 June

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 is available for someone who is driven to protect the public interest.

CLINICAL ANALYST: MANAGED CARE ORGANISATIONS (MCO) – (Patterson Grade – C4)

The purpose of the role is to oversee the accreditation of managed care organisations, ensure effective monitoring of accredited
entities, and promote compliance with managed care requirements by self-administered schemes. As a Clinical Analyst, you
will be responsible for:

▪ Managing the assessment of new, renewal, and additional managed care service applications for MCOs and selfadministered schemes, ensuring compliance with legislative and accreditation requirements.

• Evaluate and assess new and renewal applications.
• Assess applications for additional accreditable managed care services by MCOs and self-administered schemes, and
  issue updated accreditation or compliance outcomes.
• Prepare reports and recommendations, participate in Council proceedings on the suspension or withdrawal of
  accreditation, publish notices on the Council website, review responses received, and implement Council decisions.
• Review, update, and publish managed care accreditation documents in consultation with stakeholders.
  ▪ Conducting on-site evaluations of the resources, skills, infrastructure, capacity, and compliance of MCOs and selfadministered schemes against accreditation standards, and preparing reports for the Regulation Senior
  Management Meeting, Regulatory Decisions Committee and Council.
• Conduct on-site evaluations by identifying, documenting, and addressing instances of non-compliance appropriately.
• Prepare clear and comprehensive reports.
• Assess on-site compliance with managed care accreditation standards.
  ▪ Evaluating responses to accreditation conditions to ensure managed care organisations retain accreditation and
  self-administered schemes remain compliant in line with compliance initiatives.
• Analyse evidence of compliance thoroughly, examine information critically, and address issues effectively.
• Escalate matters needing intervention to the relevant internal units.
• Ensure entities comply with Council-imposed conditions within the specified timeframes and as outlined in the
  accreditation or compliance certificates.
  ▪ Monitoring the financial soundness of accredited and risk-bearing managed care organisations by ensuring the
  submission and analysis of annual financial statements within four months of the financial year-end.
• Oversight role of actual analysis performed by the accreditation analyst with the appropriate financial skills.
  ▪ Investigating complaints and supporting the Complaints Adjudication and Clinical units in resolving complaints
  against accredited managed health care organisations.
  ▪ Undertaking assignments/tasks allocated by the line manager in accordance with CMS’s 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. A
  post-diploma qualification in clinical or public health will be an added advantage.
• Minimum of three (3) years’ clinical experience in the managed health care and/or medical schemes environment.
• Valid registration with the South African Nursing Council.

TECHNICAL SKILLS AND BEHAVIOURAL ATTRIBUTES

• Proficiency in clinical methodologies, clinical protocol & policy analysis, and/or development; and clinical coding
  (ICD10, CPT, UPFS, Nappi, etc.), preferably intermediate level.
• Knowledge of the Medical Schemes Industry and the Medical Schemes Act, the Medical Schemes Benefit Rule Design
  & Application, Managed care regulatory framework, practices, & organisations, and the pre-authorisation environment.
• Understanding of other legislation impacting and influencing the functioning of the CMS (POPIA, PFMA, etc.).
• Understanding of complaint resolution, critical thinking, problem-solving, and analytical skills.
• Analytical & attention to detail, working under pressure, and emotional intelligence.
• Ability to work independently and in a team.
• Good interpersonal, conflict management, negotiation, and persuasiveness skills.
• Time and project management.
• Communication skills (verbal and written), presentation, and report writing skills.
• Computer Literacy (Proficiency in MS Office applications).

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: WEDNESDAY, 24 JUNE 2026

We wish you all the best with your applications