Senior Manager

7 days ago

Pretoria, 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 In-hospital 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 evidence-based quality outcomes.
- Direct all Clinical risk and Medicine Benefits Management activities to ensure the successful attainment of strategic objectives.
- Ensure an efficient and well-functioning 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 ad-hoc 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 sub-ordinates.
- 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, problem-solving ability and administrative skills.
- Strong verbal and written communication skills.
- The ability to conduct research using a variety of academic and market-related res

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