Job title: Manager Medical Schemes - Clinical Risk Nurse
Job type: Permanent
Emp type: Full-time
Location: Johannesburg
Industry:
  • Medical Aid / Medical Schemes
Expertise:
  • Management
  • Nursing
Job published: 22/08/2019
Job ID: 32316
Contact name: Linda Pakshong
Contact email: linda@medicalplaces.com

Job Description

ROLE PURPOSE

Accountable for the implementation of tactical work plans and formulate associated procedures to minimise the financial risk of the Scheme by implementing, maintaining and improving the defined care programs with special emphasis on hospital benefit management; providing clinical support for maintaining the acceptable level of quality and hospital risk measures.

  • Provide input into the development of the sub-division’s strategy.
  • Develop a supporting tactical plan for the Clinical Risk sub-division to ensure execution of the strategic objectives and goals.
  • Drive the implementation of the tactical plan by developing and allocating operational activities, and ensuring alignment to the achievement of operational targets.
  • Ensure the establishment, maintenance and improvement of Standard Operating Procedures, policies, and guidelines relating to the Clinical Risk sub-division in consultation with the Executive: Operations.
  • Use insights gained through business information to compile reports, and metrics to measure success, inform the business decision-making process, and realign objectives.
  • Monitor and continuously evaluate progress of the sub-division’s achievements against the tactical plan and strategic objectives.
  • Investigate and provide high level input into the resolution of escalated queries received from the Operations division and third party managed care organisations to ensure effective feedback to members and in accordance with set SLA.
  • Identify and target cost drivers in the schemes healthcare expenses.
  • Develop and implement a plan to manage and monitor the return on investments of recommended and/or approved networks.
  • Develop and maintain performance measures for third party services in accordance to agreed SLA.
  • Provide input into the department’s risk register in consultation with the Manager: ARC

B Nursing degree

 

3 years Clinical Risk and 5 years experience in medical insurance.

Skills 

  • Clinical Risk management
  • Medical Knowledge
  • Business Acumen
  • Technical problem-solving
  • Financial budgeting and management processes