Manager: Disease Management ,Medicine Management and Ambulatory Care

Medshield Medical Scheme

Gauteng, South Africa


Aug 18

Accountable for the implementation of tactical work plans and formulate associated procedures to minimise the financial risk of the Scheme by implementing, maintaining, and improving the defined care programs with special emphasis on Medicine Management, Disease Management, and Ambulatory Care; providing clinical support for maintaining the acceptable level of quality and cost-effective risk measures. -Provide input into the development of the divisions strategy.-Develop a supporting tactical plan for the Clinical Risk sub-division to ensure execution of the strategic objectives and goals.-Drive the implementation of the tactical plan by developing and allocating operational activities, and ensuring alignment to the achievement of operational targets.-Ensure the establishment, maintenance, and improvement of Standard Operating Procedures, policies, clinical protocols/guidelines/formularies/ to ensure that appropriate and cost-effective treatment is rendered to members in a measurable and consistent manner relating to the Clinical Risk division in consultation with the Executive: Operations.-Use insights gained through business information to compile reports, and metrics to measure success and inform the business decision-making process and realign objectives.-Monitor and continuously evaluate the progress of the divisions achievements against the tactical plan and strategic objectives-Ensure overall provision of a cost-effective and competitive Medicine Management, Disease Management and Ambulatory Care Services-Formulate the necessary disease management programs in collaboration with the Medical Advisor and offer clinical support and guidance where necessary-Development and maintenance of performance measures to assess the quality of care in Medicine Management, Disease Management, and Ambulatory Care Services-Investigate and provide high-level input into the resolution of escalated queries received from the Operations division and 3rd party managed care organisations to ensure effective feedback to members and in accordance with set SLA.-Identify and target cost drivers in the Scheme's healthcare expenses.-Develop and implement a plan to manage and monitor the return on investments of recommended and/or approved networks.-Evaluate the quality improvement activities of managed care organizations as per contractual agreement-Offer input into the preparation of Council Appeals and Queries, PMB Queries, and Ex-gratia cases-Assisting in the conceptualisation, planning, and implementation of new managed care products-As part of a team, develops, implements, and executes management strategies with third party companies for compliance with standard guidelines, and scheme rules-Ensure compliance with legal and procedural guidelines-Performs other duties, ad hoc projects, and special assignments as required-Provide input into the divisions risk register in consultation with the Manager: ARC.-Ensure the mitigation of the divisions risk profile through the application of fraud controls and risk prevention principles and implementing sound governance and compliance processes and tools to identify and manage risks.-Responsible for the coordination and maintenance of quality risk management in line with the requirements from ISO9001:2015.-Monitor changes in the regulatory environment and ensures that appropriate operational controls are implemented to address new requirements.-Support and provide evidence to all internal, external, and ISO audit requirements.-Oversee the maintenance and enforcement of all technical-related Service Level Agreements to minimise business risk and ensure business continuity.-Ensure adherence in the Clinical Risk team to all relevant laws, policies, and Standard Operating Procedures throughout the organisation.-Provide input in the planning and compilation of the divisions annual budget aligned to the tactical delivery plans to support the implementation of set objectives.-Ensure the effective implementation, management, monitoring of the divisions budget, and mitigate and report on any variances.-Ensure the deployment of proper financial controls to manage the divisional budget.-Report on and communicate any costs improvements and shortfalls.-Build and lead an effective and cohesive team through the effective management of divisional resources.-Drive the implementation of talent acquisition, succession planning, development, and retention strategies for the division.-Ensure the enhancement of relevant knowledge and skills through continuous coaching, mentoring, and nurturing of divisional talent.-Create a high-performance culture and manage team performance effectively by translating and communicating the annual performance goals and measures into individual work plans based on agreed-upon objectives.-Ensure that the working environment contributes to improving employee engagement, recognition, and increased productivity.-Ensure that management of poor performance and disciplinary matters is in line with the Schemes policies and procedures.-Identify and mitigate internal systems and procedural barriers to enhance excellent customer service.-Build and maintain effective internal and external stakeholder relationships for the purpose of expectations management, knowledge sharing, and integration.-Represent and participate in the organisations committees and tasks teams when required.-Convene and attend meetings and present findings and business cases to relevant stakeholders when required.-Implement timeous communication on progress and challenges in achieving the tactical work plans to impacted stakeholders.-Attend industry-related forums, conferences, and workshops to gain industry insight for the purpose of business improvement.

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