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

Key Areas of Responsibility

• Provide input into the development of the division’s strategy.
• Develop a supporting tactical plan for the clinical risk sub-division to ensure the 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 division in consultation with the Executive: Operations.
• Use insights gained through business information to compile reports and metrics to measure success and inform the business decision-making process and realign objectives.
• Monitor and continuously evaluate the progress of the division’s achievements against the tactical plan and strategic objectives.
• Ensure overall provision and management of a cost-effective and competitive Hospital Benefit Management Services
• Investigate and provide high-level input into resolving 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 scheme’s 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 with the agreed SLA.
• Evaluate the quality improvement activities of managed care organisations as per contractual agreement
• Assisting in the conceptualisation, planning and implementation of new managed care products
• As part of a team, develops, implements and executes management strategies with third-party companies for compliance with standard guidelines, and scheme rules
• Ensure compliance with legal and procedural guidelines
• Performs other duties, ad hoc projects, and special assignments as required
• Provide input into the division’s risk register in consultation with the Manager: ARC.
• Ensure the mitigation of the division’s risk profile through applying fraud controls and risk prevention principles and implementing sound governance and compliance processes and tools to identify and manage risks.
• Responsible for coordinating and maintaining quality risk management in line with the requirements from ISO9001:2015.
• Monitor regulatory environment changes and ensure appropriate operational controls are implemented to address new requirements.
• Support and provide evidence to all internal, external and ISO audit requirements.
• Oversee the maintenance and enforcement of all technical-related Service Level Agreements to minimise business risk and ensure business continuity.
• Ensure adherence in the Clinical Risk team to all relevant laws, policies and Standard Operating Procedures throughout the organisation.
• Provide input in the planning and compilation of the division’s annual budget aligned to the tactical delivery plans to support the implementation of set objectives.
• Ensure the effective implementation, management, and monitoring of the division’s budget, and mitigate and report any variances.
• Ensure the deployment of proper financial controls to manage the divisional budget.
• Report on and communicate any cost improvements and shortfalls.
• Build and lead an effective and cohesive team through effectively managing divisional resources.
• Drive the implementation of the division’s talent acquisition, succession planning, development, and retention strategies.
• Ensure the enhancement of relevant knowledge and skills through continuous coaching, mentoring and nurturing of divisional talent.
• Create a high-performance culture and manage team performance effectively by translating and communicating the annual performance goals and measures into individual work plans based on agreed-upon objectives.
• Ensure that the working environment contributes to improving employee engagement, recognition and increased productivity.
• Ensure that management of poor performance and disciplinary matters in line with the scheme’s policies and procedures.
• Identify and mitigate internal systems and procedural barriers to enhance excellent customer service.
• Build and maintain effective internal and external stakeholder relationships for the purpose of expectations management, knowledge sharing and integration.
• Represent and participate in the organisation’s committees and task teams when required.
• Convene meetings and present findings and business cases to relevant stakeholders when required.
• Implement timeous communication on progress and challenges in achieving the tactical work plans to impacted stakeholders.
• Attend industry-related forums, conferences and workshops to gain industry insight for business improvement.