Clinical Manager

Position

Purpose:

The Clinical Manager is responsible for making clinically sound funding decisions for complex cases in accordance with scheme rules and evidence‑based medicine principles. The role includes providing clinical guidance, supporting operational teams, engaging with external healthcare providers, and contributing to continuous improvement of clinical processes and outcomes.

• Health‑related qualification and appropriate clinical training (Registered Nurse, Enrolled Nurse, Clinical Associate).
• Valid registration with the relevant professional body.
• More than four years’ experience in the managed healthcare industry.
• Solid knowledge of Prescribed Minimum Benefits.

• At least one year of experience in a Medical Advisory team.
• Proficiency in internet research, Outlook, and MS Office.
• Clinical coding knowledge (ICD‑10).

• Clinical Support:
  Provide clinical guidance and decision‑making support to PMB teams and Clinical Care Coordinators. Review, unpack, and investigate complex cases requiring assessment.
• Clinical Case Reviews:
  Attend daily case reviews and provide expert clinical evaluations. Ensure all funding decisions align with scheme rules and evidence-based medicine. Facilitate appropriate management and follow‑up of referred cases.
• Workflow:
  Monitor workflow queues and ensure turnaround times are consistently met.
• Knowledge and Data Management:
  Maintain accurate clinical documentation and knowledge repositories on SharePoint. Ensure all clinical notes, decisions, and insights are audit‑ready.
• Claims Management and Clinical Coding:
  Demonstrate strong understanding of clinical coding and claims processes. Assist in resolving complex claim payment issues.
• 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, Kwa Zulu‑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.