Senior Manager: Managed Care

Medihelp

Gauteng, South Africa

Permanent

Jul 7

Medihelp is looking for a dynamic Senior Manager: Managed Care to join their Operations team Responsible for the overall management of the Medicine and Healthcare divisions through the following actions:Ensure all registered Medihelp benefits are clinically defined and that protocols and algorithms are uploaded to the system;Develop clinically defined protocols and algorithms for pharmaceutical benefits;Ensure claims are paid in terms of pre-authorisation given;Ensure payment runs are monitored daily and deviations are reported; andEnsure pre-authorisations and cases are managed in accordance with system-driven protocols and algorithms.Responsible for the overall management of the Provider Administration division through the following actions:Ensure all designated service providers (DSPs) have contracts in place and that their tariffs are uploaded on the system;Ensure all DSPs adhere to protocols and tariffs;Geomap all members to appropriate DSPs;Ensure training for DSPs; andMaintain all healthcare providers details.Manage non-declaration cases.Oversee the management of high-cost admissions and high-cost cases.Serve as part of the team responsible to manage clinical disputes with the CMS.Draft, review and negotiate contracts with third-party service providers to ensure delivery of services required to manage healthcare costs.Establish an appropriate structure to achieve objectives and manage the business units actions, staff complement and resources.Compile and monitor a risk register.Ensure constant operational efficiency through innovation within areas under control.Ensure adherence to all legislative and regulatory prescripts.Continuously evaluate plans, actions and resources to ensure that objectives are achieved.Manage the budget in order to utilise resources effectively and achieve objectives.

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