Clinical Risk Manager

Hire Resolve; Sandton; On-site; ZAR 600 000 - 800 000; Full time

Job summary

A leading company is seeking a Clinical Risk Manager in Bryanston, Sandton. The role involves overseeing clinical risk management, leading teams, and ensuring cost-effective care. Candidates should have a nursing diploma and experience in fraud management. Excellent communication and analytical skills are essential. This position offers a competitive salary based on experience.

Qualifications

• Minimum of 4 years’ experience in provider utilisation and fraud management.
• In-depth understanding of South Africa’s medical landscape and relevant legislation.

Responsibilities

• Design and maintain frameworks for clinical risk management.
• Lead clinical teams and monitor performance metrics.
• Prepare reports on risk and utilisation for senior leadership.

Skills

Leadership

Analytical

Communication

Problem-Solving

Education

Registered Nursing Diploma

Matric / Senior Certificate

Certification in Claims and Forensic Risk Management

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

Tools

Microsoft Office

Job description

Job Title: Clinical Risk Manager
Location: Bryanston, Sandton, Gauteng

Hire Resolve's Client is seeking to hire a Clinical Risk Manager to join their team in Bryanston, Sandton.The Clinical Risk Manager oversees clinical risk and utilisation management, ensuring cost-effective, evidence-based care. The role includes leading a clinical team, identifying and addressing risks or fraud, and engaging stakeholders to optimise patient outcomes and service efficiency.

Key Responsibilities:Operational Management:

• Design, implement, and maintain frameworks, policies, and procedures for clinical risk management
• Resolve complex customer service issues escalated beyond junior staff
• Lead and support direct reports, ensuring performance metrics are achieved and continuously developed
• Monitor departmental performance and ensure alignment with organisational objectives

Staff Management & Leadership:

• Manage and support clinical teams, including Case Managers, Disease Management Specialists, and Nurses
• Provide training, coaching, and mentorship to enhance clinical decision-making and performance
• Conduct performance reviews and implement development plans
• Uphold service excellence standards and create a collaborative, accountable work environment

Utilisation Management:

• Oversee case authorisation and management processes to ensure appropriate and cost-effective clinical interventions
• Analyse utilisation trends to detect inefficiencies, potential fraud, and inappropriate use of healthcare services
• Lead root cause analysis, risk assessments, and incident reviews
• Ensure adherence to evidence-based protocols and benefit structures
• Engage healthcare providers and members to optimise care outcomes and resource usage
• Coordinate data and strategy with managed care and administration teams to support integrated patient care

Reporting & Stakeholder Engagement:

• Prepare and present reports on risk and utilisation to senior leadership and relevant committees
• Collaborate with internal departments and healthcare providers on clinical and risk matters
• Support quality improvement initiatives through data analysis and actionable recommendations
• Carry out any additional responsibilities as required from time to time

Qualifications:

• Matric / Senior Certificate
• Registered Nursing Diploma
• Valid registration with the South African Nursing Council (SANC)
• Certification in Claims and Forensic Risk Management
• Registration with the Association of Certified Fraud Examiners (ACFE SA)
• FAIS compliance or significant progress toward FAIS qualification (advantageous)

Skills and Experience Required:

• Minimum of 4 years’ experience in provider utilisation and fraud management
• Demonstrated ability to lead and manage clinical teams
• Previous experience within a managed care or health insurance environment
• In-depth understanding of South Africa’s medical landscape, including relevant legislation and sector dynamics
• Excellent interpersonal skills with the ability to engage stakeholders, providers, clinicians, and members effectively
• Strong analytical, problem-solving, and decision-making skills with keen attention to detail
• High ethical standards and personal/professional integrity
• Ability to manage a multidisciplinary team proactively
• Excellent written and verbal communication skills
• Proficiency in Microsoft Office applications
• Solid understanding of evidence-based medicine and health economic principles
• Capable of managing multiple priorities and making sound clinical decisions under pressure
• Comprehensive understanding of medical benefit structures and healthcare product offerings

Contact Hire Resolve for your next career-changing move.

• Salary: negotiable.
• Our client is offering a highly competitive salary for this role based on experience.
  
• You can alsovisit the Hire Resolve website:[URL Removed]or email us your CV:[Email Address Removed].com
• Alternatively, you can also contact me [Email Address Removed][Email Address Removed]
• When applying via email please use "Clinical Risk Manager" as the subject line

We will contact you telephonically in 3 days should you be suitable for this vacancy. If you are not suitable, we will put your CV on file and contact you regarding any future vacancies that arise.

Desired Skills:

• Clinical Risk Manager
• Clinical Risk Manager
• Clinical Risk Manager