Job Description

Head Medical Risk and Business Solutions - Centurion Centurion - GautengHead: Medical Risk and Business Solutions Claims Division CenturionSalary: R1.8mil paOverview:Reporting to Chief Claims Officer:The Head: Medical Risk and Business Solutions will provide leadership and expertise in relation to medical management, actuarial management and business solutions. In addition, the incumbent will be responsible for implementing crash cost analysis strategies to enable the accuracy and reduction of claims as well as crash prevention strategies (reduction of motor vehicle accident) to drive down the prevalence of motor vehicle accidents.Requirements and Knowledge:

• Bachelors degree in health sciences / medical.
• Post graduate qualification in Health sciences / Medical or related.
• Post graduate qualification in Business Management or Administration will be an added advantage.
• Registration with the HPCSA advantageous.
• Relevant 10-12 years experience in medical management and post settlement care of which 5 (five) years must have been on senior management level.

Technical:

• Understanding of the fundamental processes of business and the impact of the external/internal influences of clinical decision making.
• Experience in the management of medical protocols and the development and maintenance to medical tariffs and codes.
• Understanding actuarial models as it relates to claims management.
• Knowledge of the marketplace and professional trade associations, key people and companies.
• Understanding of the National health Policy framework and healthcare industry.
• Knowledge on continuous improvement/innovation and optimization methodologies.

Key performance Areas:Medical management:

• Provide strategic direction in developing and managing medical management within operations including medical payments claims, medical assessments and post settlement care.
• Lead and direct medical supply agreements, implement cost analysis strategies and negotiate with suppliers accordingly.
• Maintain relationships with relevant stakeholders to flag problems and risks, and proactively shape any regulatory guidance.
• Oversee the continuous improvement of medical claims processing

Strategy development and operational planning:

• Lead the Implementation of the Medical Risk and Business Solutions business strategy and plan that ensure alignment with short-term and long-term objectives.
• Lead the implementation and annual review of the overall Strategic Plan for the department.

Policy review and implementation:

• Provide direction on the development and implementation of policy, procedures and processes.
• Work with appropriate structures to ensure effective execution of policy and practices.

Claims Actuarial Management:

• Oversee the alignment of allocated funds for the claims put forward to the company.
• Lead and direct the claims actuarial analysis function.
• Lead and direct the development of the co-developed payout models that will redesign compensation packages.

Research and Business Solutions:

• Provide strategic direction in the management of business solutions, inclusive of quality management and practice guidelines.
• Analysis of medical management trends for company solutions and services.
• Ensure the application and/or execution of standard practices
• Provide strategic direction in the analysis of research data.
• Provide strategic direction and management of clinical support that is provided to the clinical research team responses to all clinically related queries of company external stakeholders

Crash Prevention Management:

• Provide strategic direction in developing and managing crash prevention strategies and road safety interventions.
• Lead and direct strategic partnerships and interventions leading to mutually beneficial partnerships by means of strategic Memorandum of Understanding and agreement for the effective reduction in motor vehicle accidents.
• Conduct research and implement analysis strategies to reduce the prevalence of motor vehicle accidents.

Stakeholder management:

• Facilitate communication with all levels of stakeholder in relation to claims risk.
• Ensure adequate representation of the Fund in relevant external activities and events i.e. medical institutions events.

Financial management:

• Provide strategic input into annual planning and budget development to support strategic operational goals.
• Develop and implement company operational Claims Risk budget.
• Ensure that the periodic financial and strategic goals of company as well as the performance expectations of the various teams within are achieved.
• Responsible to report and review Claims Risk financial and non-financial goals.
• Ensure sufficient internal control measures are implemented for adherence to PFMA and other relevant legislation and regulation.
• Manage, monitor and control the department expenses budget.

People Management:

• Ensure the sourcing, development and retention of a high-performance team.
• Ensure that recruitment of operational workforce is in line with employment equity targets.

Reporting:

• Report quarterly on progress with implementation of operational plans.
• Lead the development of functional reporting systems, for management, project or performance reporting.
• Lead and direct the development of reports/ policies/ procedures and guide the process through the alignment of these documents to the overall companys Strategy.
• Ensure regular and periodic reports are prepared and submitted as and when required to provide progress updates and/or inform management decisions.

NB: Should you not be contacted within 2 weeks of your application, please consider it as unsuccessful.Apply for this Job

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