Location
centurion, city of tshwane metropolitan municipality, South-Africa
Posted
July 24, 2026
Job Description
Position Purpose: To provide expert clinical assessment and decision making in relation to Ex gratia applications, regulatory (CMS) complaints, appeals, disputes and escalations.
Experience: 2-5 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration industry or similar.
Solid working experience with the following:
Appeals and Disputes Management
- Review and assess clinical appeals and disputes in line with scheme rules and clinical guidelines
- Analyse clinical documentation, treatment plans, and provider motivations
- Make evidence-based recommendations on benefit funding and clinical appropriateness
- Ensure turnaround times (TATs) are adhered to
CMS Case Management
- Manage complaints and escalations received from the Council for Medical Schemes (CMS)
- Compile detailed, accurate, and comp...