Senior Risk Manager

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

Position Purpose: The Senior Risk Manager is responsible for providing strategic leadership, governance and oversight of the Medical Advisory Unit’s clinical risk portfolio, with specific accountability for the Appeals and Disputes Team, including Appeals, Disputes, Council for Medical Schemes (CMS) complaints, Ex-gratia funding requests and regulatory escalations.

The incumbent ensures that clinical decisions are evidence-based, legally compliant, ethically sound and aligned with Scheme Rules, the Medical Schemes Act, Prescribed Minimum Benefit (PMB) Regulations and organisational policies.

The role provides strategic oversight of clinical governance, regulatory compliance, operational risk management and quality assurance while supporting Medical Advisors, Clinical Managers and Clinical Care Coordinators. The Senior Risk Manager also acts as the principal liaison with the Council for Medical Schemes and works closely with the Health Policy Unit, Legal Services, Clinical Operations and Scheme stakeholders to mitigate organisational risk and improve clinical decision-making.

Key Responsibilities:

Strategic Leadership and Risk Management

• Lead the Appeals and Disputes Team, providing strategic direction and oversight of Appeals, Disputes, Ex-gratia requests, CMS complaints, and other clinical risk functions.
• Drive a culture of clinical excellence, accountability, continuous improvement, and sound risk management.
• Clinical Governance and Decision Oversight
• Provide oversight of complex clinical funding decisions, ensuring consistency, fairness, and alignment with evidence-based medicine, Scheme Rules, PMB Regulations, and relevant legislation.
• Monitor clinical quality and support governance structures to promote appropriate and cost-effective healthcare funding decisions.
• Regulatory Compliance and Clinical Risk
• Ensure compliance with the Medical Schemes Act, PMB Regulations, CMS requirements, POPIA, and organisational policies.
• Identify, assess, and mitigate clinical, operational, and regulatory risks while maintaining effective governance and audit readiness.
• Stakeholder Engagement and Advisory
• Build and maintain strategic relationships with internal and external stakeholders, including the Council for Medical Schemes, healthcare providers, Scheme representatives, Legal, and the Health Policy Unit.
• Provide expert clinical and regulatory advice on complex cases, policy matters, complaints, and escalations.
• Operational Performance and Continuous Improvement
• Monitor operational performance, case trends, turnaround times, and quality indicators to identify improvement opportunities.
• Lead process optimisation initiatives and support the implementation of operational and system enhancements.
• People Leadership and Capability Development
• Lead, coach, and develop the Appeals and Disputes Team to foster high performance, clinical excellence, and professional growth.
• Promote knowledge sharing, succession planning, and continuous learning across the Medical Advisory Unit.
• Reporting and Business Intelligence
• Analyse clinical, operational, and risk data to identify trends and emerging risks.
• Prepare reports and provide strategic recommendations to support executive decision-making and organisational objectives.

Minimum Qualifications:

• Health related qualification and appropriate Medical/Clinical training: Professional Registered Nurse
• Valid registration with the relevant professional body
• More than 10 years in managed healthcare industry experience
• Sound knowledge of Prescribed Minimum Benefits

Advantageous

• At least 2 years as a clinical specialist in a Medical Advisory team
• Computer literacy especially with respect to Internet searches, Research, Outlook and MS Office
• Clinical coding knowledge of ICD-10

Experience

• Managed healthcare and Medical Advisory
• Clinical governance and risk management
• Appeals, Disputes, Ex-gratia and CMS case management
• Healthcare funding and PMB administration
• Regulatory compliance and audit governance
• Clinical leadership and people management
• Stakeholder engagement and relationship management
• Operational management and process improvement
• Claims management and clinical coding

Knowledge

• Medical Schemes Act and PMB Regulations
• Council for Medical Schemes (CMS) framework
• Managed healthcare and healthcare funding
• Clinical governance and evidence-based medicine
• Scheme Rules and healthcare legislation
• Risk management and corporate governance
• POPIA and regulatory compliance
• ICD-10 and clinical coding principles

Skills

• Strategic leadership and decision-making
• Clinical judgement and risk management
• Analytical thinking and problem-solving
• Stakeholder engagement and negotiation
• Communication, report writing and presentation
• People leadership, coaching and mentoring
• Project, change and process management
• Data analysis and interpretation
• Financial and business acumen
• Microsoft Office and clinical systems proficiency
• Strategic mindset
• Drives results
• Ensures accountability
• Collaborates and builds relationships
• Manages complexity
• Cultivates innovation
• Instils trust
• Business insight
• Action orientation
• Organisational savvy

Note: Company reserves the right to close the advert before specified closing date.

PHA has its head office in Centurion, Gauteng. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.