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.
• 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.