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  • 6 days ago

jobs description

Job Purpose

This role develops and implements compliant benefits to provide optimal healthcare services to members in a financially sustainable manner. It develops and implements effective, data analytics-driven, evidence-based healthcare delivery strategy to deliver optimal healthcare provision coverage and health outcomes. The role identifies opportunities for optimisation of healthcare costs, whilst ensuring delivery of quality healthcare services to members; and monitors implementation of healthcare provision including risk assessment, managed care and clinical support programmes, and provider networks. The role executes effective clinical governance and clinical audit practices within POLMED. The role serves as medical advisor to the Scheme and the Clinical Governance Committee.


Benefit design and medical policy management
• Identifies member needs through structured research insights gathered from multiple data sources;
• Updates and creates new benefits to... provideoptimum healthcare solutions to members whilst ensuring the integrity and financial health of the scheme;
• Reviews, manages and updates benefits schedules and policies in line with member needs,Polmed's strategy and rules;
• Manages ex-gratia payments in line with scheme strategy;
• Develops or adjusts protocols based on advances in the health care industry and research insights; and
• Communicates changes and provide training to relevant stakeholders (Administrator, MCO, providers and members).

Managed Care Management
• Develops the managed care strategy for Polmed in line with scheme rules;
• Proposes scheme rules amendments in line with CMS regulations;
• Contributes to specifications for MCO services for effective healthcare risk management through condition prevention, managed care and clinical support programmes;
• Develops, reviews and monitors implementation of disease management programmes
• Develops KPIs and targets and establishes monthly review mechanisms to monitor delivery against SLA; and manage deviations for effective contract management and cost effective and efficient managed care;
• Executed clinical governance and clinical audit; and
• Identifies and seeks opportunities to maximise savings opportunities on managed care whilst ensuring members are not compromised.

Provider Network Management
• Develops network strategy and coordinated care strategy for Polmed and champion its implementation;
• Manages performance of the MCO with respect to provider and facilities within the managed care networks in delivery of services by tracking accreditation, compliance, capacity and quality checks against member benefits and needs;
• Develops and oversees implementation of Provider Profiling Programme including Profiling Frameworks, Peer Review Frameworks and refining Alternative Reimbursement Models;
• Acts as an escalation path for provider queries, complaints and issues; and
• Effective relationship with SAPS to optimise healthcare delivery facilities.

Wellness Management
• Develops and oversees implementation of the Polmed's wellness strategy and interventions through effective partnership with SAPS and monitoring performance of wellness providers;
• Develops and monitors implementation of preventative care programmes; and
• Monitors uptake of wellness interventions and tracks impact on member health outcomes.

Strategic Management
• Contribute to the development of the Operations Departmental operational plan, flowing from Polmed strategy;
• Cascade the Operations Departmental operational plan to Clinical Services for line of sight and alignment;
• Monitor performance and report regularly to Executive on the overall progress and results against Operational Plan and initiate courses of action for improvement; and
• Ensure adherence and compliance to reporting requirements, including timelines, templates and frameworks.

Stakeholder Management
• Communicate the vision and objectives of Polmed Clinical Services strategy to internal and external stakeholders;
• Forges beneficial relationships with SAPS at various levels to facilitate health outcome improvement;
• Lobby executive support and buy-in for relevant Clinical Services initiatives;
• Ensure the effective integration between Clinical Services and Member Experience and Engagement as well as the Marketing Unit;
• Manage relationships with MCO outsource partners and facilitate beneficial relationships;
• Oversee the integration services with SAPS' health risk manager;
• Champion in leading implementation of new Clinical Services initiatives; and
• Provide regular feedback on progress and highlight or escalate snags and problems immediately as they occur.
• Extensive travelling

People Management
• Build a positive staff and team culture and a climate that attracts, retains and motivates staff;
• Manage staff under supervision and conduct performance and talent management activities for direct reports;
• Coach and mentor direct reports;
• Oversee effective utilization of systems and tools to ensure that knowledge is managed efficiently for continuous improvement; and
• Recognise and make recommendations for the reward of high performing members; respects, promotes and accepts diversity.

Financial Management
• Responsible for development and administration of the functional area's budget;
• Ensure adherence to approved budget;
• Manage and monitor budget through managing variances in actual vs. budget expenditure in all areas of accountability; and
• Develop and implement measures to improve the functional area's cost management.

Compliance and Governance
• Executes in adherence to all relevant regulatory and business practices;
• Active risk management by applying and promoting a culture of ongoing detection and resolution of Statutory, Regulatory Compliance breaches;
• Execute all Internal Audit exceptions and ensure the implementation of preventative measures in the unit; and
• Drive the resolution management of the identified top 5 Internal Audit ris

• Live and exemplify the Polmed values

Qualification & Experience

Minimum Requirement


Registration with the HPCSA

Qualification in Public Health or Family Medicine will be an added advantage.

8 years' experience in Clinical Services in medical schemes

6 years management experience

Demonstrate deep knowledge of medical scheme clinical services

5 years' experience in private practice

Desired Skills
• See above spec
Pretoria South Africa


Apply - Senior Manager: Clinical Services Pretoria