Position: Clinical Care Coordinator: Appeals and Disputes Team (ADT) Location: Centurion, Gauteng Position Purpose: To provide expert clinical assessment and decision making in relation to Ex gratia applications, regulatory (CMS) complaints, appeals, disputes and escalations. Qualifications & Experience: Registered Nurse with medical diploma/degree and valid SANC registration (MANDATORY REQUIREMENT) 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 compliant case responses within required timelines Liaise with internal stakeholders to gather relevant clinical and administrative information Ensure alignment with the Medical Schemes Act and CMS rulings Ex‑Gratia Case Review Evaluate ex‑gratia requests based on clinical merit, financial impact, and member circumstances Prepare structured case summaries and recommendations for internal committees Ensure decisions are well‑motivated, consistent, and documented Clinical Assessment & Decision Support Interpret clinical data, ICD‑10 codes, treatment protocols, and PMB regulations Apply managed care principles to ensure cost‑effective and appropriate care Escalate complex or high‑risk cases to senior clinical staff where necessary Stakeholder Engagement Communicate effectively with healthcare providers, members, and internal departments Provide clear, professional written responses for disputes and appeals outcomes Participate in multidisciplinary discussions and case reviews Compliance and Governance Ensure all decisions comply with: Medical Schemes Act Prescribed Minimum Benefits (PMB) regulations Scheme rules and policies Maintain accurate and auditable records of all cases Support internal and external audits Accountabilities Client service delivery and quality Follow procedures and cooperate with peers and leader for best possible service delivery Contribute to cost savings within the department to assist with financial goals and targets Operation Model Meet delivery objectives through working with other team members within and linked to the department / project Resolve operational performance variations and problems and elevate unresolved issues to higher levels Ensure accuracy and quality of clinical reviews and compliance with regulatory and Scheme requirements Evaluate medical records, ICD‑10 codes, treatment plans and care pathways Review and assess requests for benefits outside the Scheme rules based on clinical necessity, severity and exceptional circumstances and ensure consistency, fairness and ethical decision making Provide clinical input and analysis for responses to CMS complaints, escalations, appeals and disputes and draft clear accurate feedback Review case histories to identify compliance gaps, clinical risk or opportunities for training and development Maintain a high level of impact on other departments to support improved delivery – continually increase understanding of client and stakeholder needs, satisfaction and service delivery Be a member of related professional bodies Ensure CPD (continual professional development) or similar accreditation requirements are met annually to maintain specialist accreditation Operational Implementation of Strategy Keep up to date with operational changes implemented in response to important external influences Deliver in a manner that supports and meets operational quality standards and meets the defined departmental priorities Perform according to defined operational best practice and identify and implement opportunities for continuous delivery improvement Deliver personal performance within Human Capital frameworks and policies to ensure delivery to agreed standards and objectives Engage in development, coaching and mentoring Support transformation through valuing diversity Stakeholder Management Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully achieved Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy‑in Liaise with internal teams, treating providers and external stakeholders where required KEY PERFORMANCE AREAS Logical exploration of problems with innovative solutions Able to work with, and encourage participation in, team efforts Able to handle concurrent tasks Committed to good business ordinance, maintaining an effective internal control environment Able to manipulate data to produce management information KEY COMPETENCIES Experience Compliance and Governance Medical Schemes Act Prescribed Minimum Benefits (PMB) regulations Scheme rules and policies Maintain accurate and auditable records of all cases Support internal and external audits Able to communicate effectively with and influence actions of others not under their control Negotiation Skills and Telephone Etiquette Knowledge Application of processes, procedures, and analytical skills Knowledge of relevant legislation and strong understanding of Prescribed Minimum Benefits and Medical Scheme legislation Product and scheme rule knowledge Contribute to continuous improvement of clinical review processes and guidelines Skills Risk awareness, management and mitigation Good business ordinance, maintaining an effective internal control environment Time management Analytical Ability Numerical Ability Attention to Accuracy and Detail Problem Solving Customer Focus Communication Skills – both written and verbal Ability to work independently and manage multiple complex cases Ethical reasoning and fairness Emotional Intelligence, strong clinical judgment and professionalism Analytical and critical thinking Note: Company reserves the right to close the advert before specified closing date. PHA has its head office in Westville, KwaZulu‑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. #J-18808-Ljbffr