Our client, a leader in medical aid schemes and financial services, is seeking to employ an experienced Senior Manager Clinical Risk Management to join their dynamic team based in Melrose Arch, Johannesburg.

Awesome career opportunity awaits!

Requirements:

• Matric / Grade 12.
• Registered Clinical Professional (Registered Nurse, Doctor, Pharmacist, etc.).
• Postgraduate qualification in Health Economics, Public Health, Managed Care, or Business Management (preferred).
• 8–12 years in managed care, clinical risk, hospital management, or related fields.
• Minimum 5 years in a senior leadership role.
• Minimum 5 years within medical schemes, healthcare funders, or financial services (healthcare).
• Clinical governance expertise.
• Data interpretation and health analytics.
• Regulatory knowledge (MSA, PMBs, CMS guidelines).

Responsibilities:

Strategic & Leadership Responsibilities

• Develop and implement the Clinical Risk Management Strategy and annual operational plan.
• Provide leadership to managed care, clinical operations, and risk units.
• Advise Executive and Board Committees on clinical risks and mitigation strategies.
• Lead clinical policy formulation, including benefit design, clinical protocols, and funding guidelines.
• Drive transformation, continuous improvement, and innovation in clinical risk approaches.

Clinical Governance & Compliance

• Ensure clinical governance frameworks and monitoring systems are implemented.
• Oversee compliance with healthcare legislation and regulatory standards.
• Develop and maintain evidence-based clinical policies, pathways, and protocols.
• Monitor compliance with benefit rules, clinical guidelines, and risk controls.

Utilisation & Cost Management

• Oversee utilisation management programmes, including pre-authorisation, case management, and chronic benefit management.
• Analyse utilisation trends, hospitalisation patterns, and high-cost drivers.
• Lead cost containment initiatives and support provider contracting strategies.
• Manage high-risk clinical cohorts and catastrophic cases.

Provider Risk & Network Management

• Monitor provider behaviour, billing trends, and quality-of-care indicators.
• Implement risk-sharing models, DSP performance reviews, and quality frameworks.
• Provide clinical input into provider contracting strategies and tariff decisions.

Disease & Population Risk Management

• Oversee disease management programmes and population risk initiatives.
• Implement predictive modelling and early-risk identification tools.
• Manage high-risk and chronic cohorts to improve outcomes and reduce avoidable costs.

Fraud, Waste & Abuse (Clinical Component)

• Support clinical investigations into fraud, waste, and abuse.
• Provide clinical interpretation of irregular billing and provider behaviour.
• Implement preventative clinical controls to reduce leakage.

Data Analytics, Reporting & Insights

• Use actuarial, clinical, and utilisation data to inform decision-making.
• Produce dashboards, reports, and clinical risk insights.
• Track key performance metrics, cost trends, and health outcomes.

Stakeholder Management

• Engage with healthcare providers, regulators, and managed care partners.
• Manage key internal relationships with Finance, Actuarial, and Member Services.
• Represent the organisation in clinical forums and regulatory engagements.

People & Operational Management

• Lead and develop multidisciplinary clinical and analytical teams.
• Manage budgets, resources, and operational efficiency.
• Ensure service levels, turnaround times, and member experience standards.

Please note that if you do not receive feedback within two (2) weeks of applying, kindly consider your application unsuccessful.