Clinical Risk Manager

Unity Health; Johannesburg; On-site; ZAR 30 000 - 60 000; Full time

Job summary

An established industry player in primary healthcare is seeking a Clinical Risk Manager to enhance healthcare solutions for South Africans. This role involves overseeing clinical risk management, leading a multidisciplinary team, and ensuring high standards of patient care. The successful candidate will develop frameworks and policies while managing complex service issues. With a focus on ethical practices and evidence-based decisions, this position offers a unique opportunity to shape the future of healthcare in the region. If you are passionate about making a difference and possess strong leadership skills, this could be the perfect fit for you.

Qualifications

• 4+ years in provider utilisation and fraud management.
• Strong leadership in clinical team management.
• Thorough understanding of SA's medical landscape.

Responsibilities

• Develop and maintain clinical risk management frameworks.
• Lead and manage clinical Case Managers and Nurses.
• Compile risk and utilisation reports for senior management.

Skills

Provider Utilisation Management

Fraud Management

Clinical Team Leadership

Interpersonal Skills

Analytical Skills

Communication Skills

Evidence-Based Medicine

Decision-Making Skills

Education

Matric

SANC Membership

Claims and Forensic Risk Management Certification

Registration with ACFE SA

Job description

2 weeks ago, be among the first 25 applicants. Direct message the job poster from Unity Health.

Unity Health is a well-established primary healthcare provider in the South African market.

Our mission is to offer primary healthcare insurance solutions to the vast majority of South Africans who are unable to afford medical scheme coverage.

Job Title: Clinical Risk Manager

Qualifications:

• Matric
• Valid membership of SANC
• Claims and Forensic Risk Management Certification
• Registration with the Association of Certified Fraud Examiners (ACFE SA)
• FAIS compliant or significant progress toward (advantageous)

Skills and Experience:

• A minimum of four years' experience in provider utilisation and fraud management
• Proven experience in leading and managing clinical teams
• Experience within a managed care or health insurance environment
• A thorough understanding of SA's medical terrain - legislation, growth opportunities, etc.
• Strong interpersonal skills and the ability to engage various parties appropriately (Stakeholders, providers, clinicians & members)
• Strong analytical and problem-solving skills with attention to detail
• Superior judgment, negotiation, and decision-making skills
• Strong ethics and a high level of personal and professional integrity
• Ability to proactively manage a multidisciplinary clinical team
• Excellent verbal and written communication skills
• Sound understanding of evidence-based medicine principles and health economic principles and tools
• Ability to manage multiple priorities and make sound clinical decisions under pressure
• Understanding of the company's products and services

Reporting to: Operations Executive

Scope of Responsibility:

1. Day-to-day Operations
2. Develop, implement, and maintain clinical risk management frameworks, policies, and procedures.
3. Manage and resolve complex customer service issues.
4. Manage, engage, and develop direct reporting staff, ensuring KPIs are monitored and improved.
5. Ensure departmental milestones are met.

Staff Management and Leadership:

1. Lead and manage a team of clinical Case Managers, Disease Management Specialists, and Nurses.
2. Provide coaching, mentorship, and training.
3. Conduct performance reviews and staff development.
4. Manage the clinical department to high standards.
5. Foster a positive, collaborative team culture.
6. Oversee authorisation and case management processes.
7. Monitor utilisation data to identify inefficiencies, fraud, and service overuse/underuse.
8. Conduct risk assessments, root cause analyses, and incident investigations.
9. Lead interventions to improve clinical appropriateness and cost-effectiveness.
10. Ensure clinical decisions are evidence-based and aligned with protocols.
11. Develop processes for optimal utilisation and managed care engagement.
12. Coordinate with healthcare providers and members.
13. Share data and interventions within teams to ensure optimal patient care.

Reporting and Stakeholder Engagement:

1. Compile and present risk and utilisation reports to senior management.
2. Liaise with providers, internal departments, and management on clinical and risk issues.
3. Support quality improvement and audit processes with data insights.
4. Perform other duties as assigned.

Changes: The company reserves the right to modify this job description at its discretion.

Applications:

• Increase your chances of interviewing at Unity Health by 2x.
• Get notified about new Clinical Risk Manager jobs in City of Johannesburg, Gauteng, South Africa.

We're unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.