Senior Manager

2 weeks ago

Pretoria, Gauteng, South Africa Tych Business Solutions Full time

Job ID: 53663
Date Posted: Posted 1 week ago
Location: Pretoria
Job Title: SENIOR MANAGER - CLINICAL RISK MANAGEMENT - PERSONS WITH DISABILITIES - PRETORIA

Duties:

  • Manage, set up and drive the Clinical Risk and Medicine Benefits management programme internally and externally (SPNs).
  • Manage service providers to ensure Disease Risk Management (DRM) programmes are effectively and efficiently managed.
  • Manage service providers to ensure that Pharmaceutical Benefits are utilised effectively and efficiently by members.
  • Manage, drive and set up a case management programme to drive Inhospital case management, early discharge planning and Subacute/ Stepdown programmes.
  • Lead and mentor staff within the Clinical Risk Management (CRM) functional unit.
  • Maintain relationships within the healthcare industry and stay abreast of new developments that impact Clinical risk management.
  • Required to assist and provide support with the review of the Scheme's policies, protocols and formularies from a clinical and financial position.
  • Provide clinical risk management support to the Healthcare Management Division.
  • Ensure that all risk areas applicable to Healthcare Management are identified, communicated and strategies put in place to mitigate risk.
  • Manage the process for development and maintenance of Clinical Risk and Medicine benefits management standard operating procedures and policies.
  • Drive Clinical Risk and Medicine Management efficiency to deliver clinically approved and evidencebased quality outcomes.
  • Direct all Clinical risk and Medicine Benefits Management activities to ensure the successful attainment of strategic objectives.
  • Ensure an efficient and wellfunctioning Clinical risk and Medicine Benefits Management platform.
  • Contribute to targeted research into local and international clinical guidelines and funding policies for Clinical risk and Medicine Benefits management.
  • Evaluate current cost drivers, and trends and compare them with those of local and international sources for best practice.
  • Monitor and drive all activities managed care activities related to Clinical Risk and Medicine management.
  • Review and provide expertise on new Health Technology assessments for Clinical risk management.
  • Develop and maintain adequate knowledge of data handling and interpretation of information translating interventions.
  • Provide Clinical Risk and Medicine management technical support when the Scheme is having difficulties in defined areas, working closely with the team to sort out any challenges.
  • Perform tasks timeously, accurately and with necessary detail in response to issues raised.
  • Review, revert and ensure all CMS circulars are responded to and timeously implemented.
  • Review and maintain and updated PMB and CDL lists.
  • Support the Scheme's Expert Advisor Platforms.
  • Provide input and support to the clinical committees, external advisory panel and other committees as and when required.
  • Assist with all adhoc requests on any clinical and disease risk management matters.
  • Participate in interdisciplinary committees within the Scheme.
  • Participates in clinical projects/studies and interdisciplinary meetings as required.
  • Support Scheme's product development and benefit design activities.
  • Manage, people, processes and systems internally and externally (SPNs) staff where necessary who are subordinates.
  • Ensure compliance with CMS regulations.

Qualifications, skills and competencies requirements are:

  • Minimum 3-year degree or diploma in Clinical Sciences (medical/ nursing/ physiotherapy/psychology etc.).
  • A Bachelor of Pharmacy degree will be advantageous.
  • Minimum 8 years of work experience in the medical aid industry.
  • Minimum 4 years as Manager/Supervisor in the healthcare funding/ medical Scheme industry.
  • Experience in medicine pricing, reimbursement of pharmaceutical services and managed care processes related to pharmaceutical benefits management is essential.
  • Experience in Clinical Risk Management and Pharmaceutical Benefits Management
  • Product Development and Benefit Design Experience
  • Managed Care Experience
  • Sound Clinical Knowledge of hospital medical practice across all disciplines and their therapeutic modalities.
  • Experience in Clinical analytics.
  • Sound qualitative and quantitative analytical skills.
  • Must be in possession of a valid driver's license and own vehicle and be willing to travel at short notice.
  • A good understanding of all coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more).
  • A good understanding of managed care processes.
  • A good understanding of Clinical Risk and Medicine Benefits Management.
  • A good understanding of the Medical Schemes Act, Pharmacy Act, Medicines and Related Substances Act etc.
  • Strong Analytical, problemsolving ability and administrative skills.
  • Strong verbal and written communication skills.
  • The ability to conduct research using a variety of academic and marketrelated res

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