About the position
Operational oversight of clinical risk, quality, and staff performance within the Hospital Risk Management department which includes pre-authorisation case management and clinical auditing.
Strategic leadership to drive continuous improvement, cost efficiency, innovation, and alignment to the Scheme's overall managed care strategy.
Key Performance Areas (KPAs)
Responsible for the design, development, implementation and monitoring of all hospital-based risk management to improve access to and ensure high-quality, cost-effective management of entire hospital incidents.
Promote a culture of accountability and professionalism, while developing systems, policies, and initiatives that proactively reduce clinical
KEY RESPONSIBILITIES
Clinical and Risk Management
- Lead continuous clinical, medical, and surgical risk evaluations, and report to the Scheme and company.
- Participate in the Clinical Review Team to support scheme and medical advisor decision-making.
- Stay current with clinical knowledge and new treatment modalities.
- Develop and implement clinical protocols, guidelines, and processes that drive quality and performance.
- Liaise with healthcare providers, scheme networks, and external stakeholders to manage member care pathways and mitigate clinical risks.
- Occasionally accompany case managers for onsite reviews of complex, high-risk cases.
- Analyse claims data and audit results to recommend targeted interventions that reduce fraud, waste, and abuse.
- Respond to Council for Medical Schemes (CMS) member complaints related to the department
Product & Scheme Development
- Assist with the conceptualisation, planning, and implementation of new managed care products.
- Contribute to medical scheme product development and benefit design.
- Stay abreast of industry developments, healthcare legislation, and regulatory requirements.
- Participate in tariff negotiations with hospital groups.
- Liaise with the Principal Officer and Medical Advisor for clinical alignment and strategic decision making
Operational Management
- Oversee day-to-day departmental operations and address operational inefficiencies.
- Ensure alignment of departmental performance with scheme sustainability goals and budget targets.
- Monitor and evaluate internal and external communication flows.
- Manage internal processes for confidential staff admissions, including pre-authorisation and appropriate claims payment.
- Coordinate weekly, monthly, and quarterly reports to business, schemes, and external hospital groups.
- Ensure adherence to SLAs and other compliance metrics.
Process Improvement & Systems
- Oversee the management and review of clinical SOPs, training manuals, and workflow documentation.
- Lead the implementation of new systems and process enhancements (e.g., IMed, Curus, Workflow, Billing Rules).
- Collaborate with Business Liaison and IT on system improvements; responsible for user testing and sign-off.
- Project manage new initiatives and enhancements from planning through to execution, including training and change management.
Leadership & People Management
- Provide coaching, mentoring, performance management, and quality control for team members.
- Drive a culture of accountability, professionalism, and service excellence.
- Manage staff KPAs, conduct quality control feedback sessions, and support disciplinary processes where necessary.
- Identify and develop talent through succession planning and continuous professional development.
QUALIFICATIONS AND EXPERIENCE
- Registered Nurse or Pharmacist
- A Minimum of 5-7 years experience in managed healthcare, hospital management clinical governance or medical scheme operations
- 3 years in a management or leadership role with experience managing clinical teams and driving strategic initiatives
- Legislation relating to the work of medical schemes
- A valid drivers licence is essential
Desired Skills:
- Registered Nurse or Pharmacist
- extensive experience within managed healthcare
- strong management skills
- extensive knowledge of hospital risk management within the medical schemes industry