Senior Clinical Risk & Appeals Leader

Private Health Administrators (Pty) Ltd; Centurion; On-site; ZAR 1,100,000 - 1,500,000; Full time

Job summary

Private Health Administrators (Pty) Ltd is seeking a Senior Risk Manager to provide strategic leadership over the Medical Advisory Unit's clinical risk portfolio, including Appeals, Disputes, CMS complaints, and PMB regulatory escalations.

The role ensures evidence-based, legally compliant, and ethically sound clinical decisions, partnering with Legal, Health Policy, and Clinical Operations to mitigate risk.

Qualifications

• Health-related qualification and Professional Registered Nurse registration.
• Minimum 10 years in managed healthcare.
• Knowledge of Prescribed Minimum Benefits (PMB) Regulations.

Responsibilities

• Lead the Appeals and Disputes Team with strategic direction.
• Oversee clinical governance, regulatory compliance and risk management.
• Provide expert clinical and regulatory advice on complex cases and escalations.
• Monitor performance metrics and drive process improvements.
• Develop and mentor the Appeals and Disputes Team.

Skills

Strategic leadership

Clinical judgement

Analytical thinking

Stakeholder engagement

Communication

People leadership

Project management

Data analysis

Financial acumen

Microsoft Office

Strategic mindset

Drives results

Organisational savvy

Education

Professional Registered Nurse

Tools

MS Office

Clinical systems

Job description

Private Health Administrators (Pty) Ltd is seeking a Senior Risk Manager to provide strategic leadership over the Medical Advisory Unit's clinical risk portfolio, including Appeals, Disputes, CMS complaints, and PMB regulatory escalations.

The role ensures evidence-based, legally compliant, and ethically sound clinical decisions, partnering with Legal, Health Policy, and Clinical Operations to mitigate risk.