Senior Manager: Managed Care

2 weeks ago


Pretoria, Gauteng, South Africa Medihelp Medical Scheme Full time
Responsible for the overall management of the Medicine and Healthcare (pre-auth, case management and hospital audit) divisions through the following actions:
Ensure all registered Medihelp benefits are clinically defined and that protocols and algorithms are uploaded to the system;
Develop clinically defined protocols and algorithms for pharmaceutical benefits;
Ensure claims are paid in terms of pre-authorisation given; and
Ensure pre-authorisations and cases are managed in accordance with system-driven protocols and algorithms.
Responsible for the overall management of the Provider Administration division through the following actions:
Ensure all designated service providers (DSPs) have contracts in place and that their tariffs are uploaded on the system;
Ensure all DSPs adhere to protocols and tariffs;
Ensure training for DSPs; and
Maintain all healthcare providers' details.
Oversee the management of high-cost admissions and high-cost cases.
Serve as part of the team responsible to manage CMS complaints.
Draft, review and negotiate contracts with third-party service providers to ensure delivery of services required to manage healthcare costs.
Identify areas for improvement on processes, e.g. business to business initiatives and process automation.
Establish an appropriate structure to achieve objectives and manage the business unit's actions, staff complement and resources.
Compile and monitor a risk register.
Ensure constant operational efficiency through innovation within areas under control.
Ensure adherence to all legislative and regulatory prescripts.
Continuously evaluate plans, actions and resources to ensure that objectives are achieved.
Manage the budget in order to utilise resources effectively and achieve objectives.

Paterson D5:

An applicable clinical tertiary diploma.
Eight years' relevant experience, of which two years must be in managed care and four years on management level.

Paterson E1:

Four-year clinical degree.
Eight years' relevant experience, of which two years must be in managed care and four years on management level.

Must possess knowledge of the following:
The Medical Schemes Act and Regulations;
Managed healthcare programmes, processes and systems.
Coding (ICD-10, PMB, NAPPI, CPT and RPL); and
Industry practices and trends.
Computer literate in MS Office (advanced).
Agile Leadership competencies (Delivering results, Empowering others, Continuous improvement)
Enabling competencies (Data analytics, Solutioning complexity)
Core competencies (Collaboration & Teamwork, Managing Resources, Communicating with impact, Customer focus, Planning & Organising)

Closing date: 3 March 2023

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