About the position
This role develops and implements compliant benefits to provide optimal healthcare services to members in a financially sustainable manner. It develops and implements effective, data analytics-driven, evidence-based healthcare delivery strategy to deliver optimal healthcare provision coverage and health outcomes. The role identifies opportunities for optimisation of healthcare costs, whilst ensuring delivery of quality healthcare services to members; and monitors implementation of healthcare provision including risk assessment, managed care and clinical support programmes, and provider networks. The role executes effective clinical governance and clinical audit practices within the company
KEY PERFORMANCE AREA
- Benefit design and medical policy management
- Identifies member needs through structured research insights gathered from multiple data sources;- Updates and creates new benefits to provide optimum healthcare solutions to members whilst ensuring the integrity and financial health of the scheme;- Reviews, manages and updates benefits schedules and policies in line with member needs, Polmed's strategy and rules;- Manages ex-gratia payments in line with scheme strategy;- Develops or adjusts protocols based on advances in the health care industry and research insights; and- Communicates changes and provide training to relevant stakeholders (Administrator, MCO, providers and members)
SUCCESS INDICATORS
- Compliant Benefits Schedules reviewed
- Protocols clinical and pharmaceutical
- Achievement of Managed Care SLA targets
Managed Care Management
- Develops the managed care strategy for the Company in line with scheme rules
- Proposes scheme rules amendments in line with CMS regulations
- Contributes to specifications for MCO services for effective healthcare risk management through condition prevention, managed care and clinical support programmes
- Develops, reviews and monitors implementation of disease management programmes- Develops KPIs and targets and establishes monthly review mechanisms to monitor delivery against SLA; and manage deviations for effective contract management and cost effective and efficient managed care
- Executed clinical governance and clinical audit; and
- Identifies and seeks opportunities to maximise savings opportunities on managed care whilst ensuring members are not compromised.
SUCCESS INDICATORS
- Managed Care strategy approved and implemented
- Achievement of Managed Care SLA targets
- Effective clinical governance
- Clinical Audit reports
Provider Network Management (15%)
- Develops network strategy and coordinated care strategy for the Company and champion its implementation
- Manages performance of the MCO with respect to provider and facilities within the managed care networks in delivery of services by tracking accreditation, compliance, capacity and quality checks against member benefits and needs
- Develops and oversees implementation of Provider Profiling Programme including Profiling Frameworks, Peer Review Frameworks and refining Alternative Reimbursement Models
- Acts as an escalation path for provider queries, complaints and issues; and
- Effective relationship with SAPS to optimise healthcare delivery facilities.
SUCCESS INDICATORS
- Network strategy and coordinated care strategy approved and implemented
- Achievement of Managed Care SLA targets
- Profiling Report
Wellness Management
- Develops and overses implementation of the Company's wellness strategy and interventions through effective perforance of wellness providers
- Develop and monitors implementation of preventative care programmes: and
- Monitors uptake of wellness interventions and tracks impact on memner health outcomes
SUCCESS INDICATORS
- Wellness Strategy approved and implemented
- Preventative car benefits utilisation improved
Strategic Management
- Contribute to the development of the Operations Departmental operational plan, flowing from Polmed strategy
- Cascade the Operations Departmental operational plan to Clinical Services for line of sight and alignment
- Monitor performance and report regularly to Executive on the overall progress and results against Operational Plan and initiate courses of action for improvement; and
- Ensure adherence and compliance to reporting requirements, including timelines, templates and frameworks.
SUCCESS INDICATORS
- Clinical Services Strategy implementation aligned to strategy
Stakeholder Management
- Communicate the vision and objectives of the Clinical Services strategy to internal nd external stakeholders
- Forges beneficial relationships with SAPS at various levels to facilitate health outcome improvement
- Lobby executive Support and buy-in for relevant Clinical Services initiatives
- Ensure the effective integration between Clinical services and member Experience and Engagement we wll as the Marketing Unit
- Manage relationships with MCO outsource partners and facilitate beneficial relationships
- Oversee the integration services with SAPS health risk manager
- Champion in leading implementation of new Clinical Services initiatives: and
- Provide regular feedback on pregress and highlight or escalate snags and problems imediately as they occur
People Management
- Build a positive staff and team culture and a climate that attracts, retains and motivates staff
- Manage staff under supervision and conduct performance and talent management activities for direct reports;- Coach and mentor direct reports
- Oversee effective utilization of systems and tools to ensure that knowledge is managed efficiently for continuous improvement; and
- Recognise and make recommendations for thereward of high performing members; respects, promotes and accepts diversity.
- Delivery effected through people
Financial Management
- Responsible for development and administration of the functional area's budget
- Ensure adherence to approved budget
- Manage and monitor budget through managing variances in actual vs. budget expenditure in all areas of accountability; and
- Develop and implement measures to improve the functional area's cost management.
- Budget managed effectively
Compliance and Governance(5%)
- Executes in adherence to all relevant regulatory and business practices
- Active risk management by applying and promoting a culture of ongoing detection and resolution of Statutory, Regulatory Compliance breaches
- Execute all Internal Audit exceptions and ensure the implementation of preventative measures in the unit; and
- Drive the resolution management of the identified top 5 Internal Audit risks.
- Compliance improved
- Risk Register maintained
QUALIFICATIONS AND EXPERIENCE
Minimum Requirement:
MBCHB
Registration with the HPCSA
8 years' experience in Clinical Services in medical schemes
6 years management experience
Demonstrate deep knowledge of medical scheme clinical services
Desired Skills:
- MBCHB
- EXTENSIVE KNOWLEDGE OF THE MEDICAL SCHEMES
- STRONG MANAGEMENT SKILLS
- MANAGED HEALTHCARE EXPERIENCE
