Long Term Insurance

Clinical Risk Manager

Sandton, Gauteng
Work Type: Full Time

Clinical Risk Manager

Our client in the healthcare insurance space in looking to employ a Clinical Risk Manager.



•            Responsible to manage the managed care department according to agreed standards and ensuring that high service levels are maintained. 

•            Must be fully versed in all aspects of the company's products and services. 

•            Manage and maintain daily operations in multiple areas – case management, disease management and risk management.

•            Is responsible for statistical reports on the team’s performance.

•            Handle and settle complicated customer service issues which cannot be resolved by junior staff.

•            Responsible for managing, engaging, and developing direct reporting staff in their day-to-day activities and ensuring key performance indicators are monitored, improved, or updated as the business develops.

•            Develop and improve processes and policies in support of the organisational goals.

•            Ensure that department milestones are met and adhered to.

•            Analyse clinical, utilisation and other data of members and healthcare providers.

•            Identify trends in utilisation, fraud and other factors and ensure processes are put in place to better manage it.

•            Develop processes to prioritise interventions and engage with healthcare providers and members to ensure optimal utilisation and care.

•            Coordinate and share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.

•            Further develop processes to manage utilisation more efficiently.

•            Develop and create reports and letters for internal and external communications.


•            Matric

•            Registered Nursing diploma

•            Valid membership of SANC

•            Claims and Forensic Risk management certification

•            Registration with the Association of Certified Fraud Examiners (ACFE SA)


Skills and Experience

•            At least four (4) years’ experience in provider utilisation and fraud management.

•            A thorough understanding of SA’s medical terrain - legislation, growth opportunities, etc.

•            Strong interpersonal skills and the ability to engage various parties appropriately for optimal outcomes.

•            Strong analytical and problem-solving skills and pays attention to detail.

•            Superior judgment, negotiation, and decision-making skills.

•            Strong ethics and a high level of personal and professional integrity.

•            Ability to liaise with external parties – clinicians and members.

•            Ability to manage a multidisciplinary team.

•            Excellent verbal and writing communication skills.

•            Computer literate – proficient in MS Office suite.

•            Sound understanding of evidence-based medicine principles and embracing health economic principles and tools.

Talent Partner:
Misan Idowu
Market related

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