CLINICAL AND OPERATIONS EXECUTIVE at MEDICAL SCHEME

To provide leadership and strategic direction to the Clinical Operations Business Unit to ensure access to evidence-based, clinically appropriate, and cost-effective quality healthcare for Scheme members in a consistent and fair manner.

Key Performance Areas And Responsibilities

Strategy, planning, and execution

• Contribute to the development and implementation of the Scheme's corporate strategy
• Develop and oversee implementation of clinical strategy for the Scheme
• Translate the Scheme's strategy into business unit goals
• Identify priorities and allocate resources accordingly
• Monitor and manage the Scheme's claims ratio to ensure financial stability and healthy solvency
• Participate as a member of the Executive team in the development of the long-term integrated, cross-functional operational plans

Clinical services and operations management

• Facilitate and implement managed care contracts, including agreed upon reimbursement models
• Maximise revenue through utilization management, claims processing, and contract performance monitoring
• Make recommendations to improve the efficiency of current systems/processes for contract development and implementation
• Manage performance of service providers contracted to the Scheme by monitoring adherence to service level agreements
• Ensure members are empowered to access and utilise the company suppliers' networks
• Implement strategies to improve utilization of wellness benefits of the Scheme
• Conduct surveys on member perceptions about products offerings and services delivery
• Chair the Clinical Operations Forum on a monthly basis with contracted service providers
• Collaborate with internal business units to facilitate requests for proposal (RFPs), and vetting of bidders
• Provide appropriate health and wellness communication and education material to encourage scheme beneficiaries to make informed decisions of their health and wellbeing
• Manage escalated queries from healthcare providers, brokers, members and the Council of Medical Schemes
• Provide clinical support to other business units
• Confer with the Operations Manager to oversee day-to-day operations of the Scheme
• Create and sustain relationships with key stakeholders within the Scheme's business ecosystem in collaboration with the Stakeholder Manager
• Coordinate and assist in the activities of the Scheme's Clinical Governance Committee, including ensuring that decisions taken by the Clinical Governance Committee, Board and Scheme Management relating to health risk management and clinical governance are executed

Product and benefit design

• Provide clinical input to the benefit design process to ensure that product development is aligned with the Scheme's strategic objectives
• Design and oversee the implementation of appropriate funding policies and clinical protocols
• Discuss current benefits and collate utilisation and service data and information for benefit design and service improvement
• Maintain the Scheme value proposition through a continuous offering of competitive cost-effective healthcare product

Budget and financial management

• Plan, coordinate, and monitor the business unit's operational budget to ensure effective allocation and optimisation of resources in meeting corporate objectives
• Analyse expenditure and cash management to ensure operations are within budget
• Provide the Chief Financial Officer (CFO) with variance reports and other financial information
• Ensure compliance with the Scheme's budget guidelines and corporate objectives

Stakeholder and brand management

• Develop and implement a relationship management strategy pertaining to clinical governance with relevant stakeholders
• Conduct monthly meetings and engage with contracted service providers to evaluate the impact of health risk strategies and quality of service delivery to the scheme beneficiaries
• Participate in industry events and thought leadership platforms in representing the Scheme
• Participate in implementation and execution of all Scheme product launches
• Manage integrity of the brand across stakeholders

Human resources management

• Provide leadership and direction to the business unit
• Manage and develop staff to ensure that the required efficiencies and effectiveness are achieved
• Manage talent and succession planning within the business unit
• Determine staffing requirements and ensure that positions are filled promptly
• Manage the performance and development of direct reports
• Create and maintain a high-performance culture within the business unit

Reporting

• Oversee preparation of clinical and managed care reports
• Provide operational updates to senior management and the Board of Trustees (BoT)
• Recommend appropriate changes to products, policies or processes to address risks identified in trend analysis
• Conduct analysis of, and input into the structure of all the relevant reports, with the aim of identifying Scheme risk, understanding benefit utilisation trends and monitoring member and provider behaviour

Governance, risk and compliance

• Lead, implement and oversee the achievement of the Scheme's health risk management and clinical governance strategic objectives
• Collaborate with the Clinical Governance Committee to ensure compliance with policies, legislation, international and local standards, and best practices
• Develop, implement and review operational policies and standard operating procedures (SOPs)
• Analyse trends in benefit utilisation by members and healthcare providers to identify potential risks to the Scheme, as well as developing risk mitigation strategies

• Medical degree plus registration with the Health Professionals Council of South Africa (HPCSA)
• Additional qualification in general management will be an added advantage

• Minimum of 10 years experience in healthcare with at least 5 years in Managed Care/Insurance/Health Administration or related environment

• Executive management
• Clinical services and operations
• Budgeting and financial management
• Product and benefit design
• Stakeholder management
• Data analytics and reporting
• Governance, risk and compliance (GRC)

• Qualified medical doctor registered with the HPCSA
• Strong background in managed healthcare or insurance or Healthcare administration