Clinical Risk Manager

Description:

Job Title: Clinical Risk Manager
Location: Bryanston, Sandton, Gauteng

Hire Resolve's Client is seeking to hire a Clinical Risk Manager to join their team in Bryanston, Sandton. The Clinical Risk Manager oversees clinical risk and utilisation management, ensuring cost-effective, evidence-based care. The role includes leading a clinical team, identifying and addressing risks or fraud, and engaging stakeholders to optimise patient outcomes and service efficiency.

Key Responsibilities:

Operational Management:

• Design, implement, and maintain frameworks, policies, and procedures for clinical risk management
• Resolve complex customer service issues escalated beyond junior staff
• Lead and support direct reports, ensuring performance metrics are achieved and continuously developed
• Monitor departmental performance and ensure alignment with organisational objectives

Staff Management & Leadership:

• Manage and support clinical teams, including Case Managers, Disease Management Specialists, and Nurses
• Provide training, coaching, and mentorship to enhance clinical decision-making and performance
• Conduct performance reviews and implement development plans
• Uphold service excellence standards and create a collaborative, accountable work environment

Utilisation Management:

• Oversee case authorisation and management processes to ensure appropriate and cost-effective clinical interventions
• Analyse utilisation trends to detect inefficiencies, potential fraud, and inappropriate use of healthcare services
• Lead root cause analysis, risk assessments, and incident reviews
• Ensure adherence to evidence-based protocols and benefit structures
• Engage healthcare providers and members to optimise care outcomes and resource usage
• Coordinate data and strategy with managed care and administration teams to support integrated patient care

Reporting & Stakeholder Engagement:

• Prepare and present reports on risk and utilisation to senior leadership and relevant committees
• Collaborate with internal departments and healthcare providers on clinical and risk matters
• Support quality improvement initiatives through data analysis and actionable recommendations
• Carry out any additional responsibilities as required from time to time

Qualifications:

• Matric / Senior Certificate
• Registered Nursing Diploma
• Valid registration with the South African Nursing Council (SANC)
• Certification in Claims and Forensic Risk Management
• Registration with the Association of Certified Fraud Examiners (ACFE SA)
• FAIS compliance or significant progress toward FAIS qualification (advantageous)

Skills and Experience Required:

• Minimum of 4 years’ experience in provider utilisation and fraud management
• Demonstrated ability to lead and manage clinical teams
• Previous experience within a managed care or health insurance environment
• In-depth understanding of South Africa’s medical landscape, including relevant legislation and sector dynamics
• Excellent interpersonal skills with the ability to engage stakeholders, providers, clinicians, and members effectively
• Strong analytical, problem-solving, and decision-making skills with keen attention to detail
• High ethical standards and personal/professional integrity
• Ability to manage a multidisciplinary team proactively
• Excellent written and verbal communication skills
• Proficiency in Microsoft Office applications
• Solid understanding of evidence-based medicine and health economic principles
• Capable of managing multiple priorities and making sound clinical decisions under pressure
• Comprehensive understanding of medical benefit structures and healthcare product offerings

Contact Hire Resolve for your next career-changing move.

• Salary: negotiable.
• Our client is offering a highly competitive salary for this role based on experience.
  
• You can also visit the Hire Resolve website: hireresolve.us or email us your CV: financialcareers@hireresolve.za.com
• Alternatively, you can also contact me directly at kay-leen.dupreez@hireresolve.us
• When applying via email please use "Clinical Risk Manager" as the subject line

We will contact you telephonically in 3 days should you be suitable for this vacancy. If you are not suitable, we will put your CV on file and contact you regarding any future vacancies that arise.

Requirements:

• Design, implement, and maintain frameworks, policies, and procedures for clinical risk management
• Resolve complex customer service issues escalated beyond junior staff
• Lead and support direct reports, ensuring performance metrics are achieved and continuously developed
• Monitor departmental performance and ensure alignment with organisational objectives

• Manage and support clinical teams, including Case Managers, Disease Management Specialists, and Nurses
• Provide training, coaching, and mentorship to enhance clinical decision-making and performance
• Conduct performance reviews and implement development plans
• Uphold service excellence standards and create a collaborative, accountable work environment

• Oversee case authorisation and management processes to ensure appropriate and cost-effective clinical interventions
• Analyse utilisation trends to detect inefficiencies, potential fraud, and inappropriate use of healthcare services
• Lead root cause analysis, risk assessments, and incident reviews
• Ensure adherence to evidence-based protocols and benefit structures
• Engage healthcare providers and members to optimise care outcomes and resource usage
• Coordinate data and strategy with managed care and administration teams to support integrated patient care

• Prepare and present reports on risk and utilisation to senior leadership and relevant committees
• Collaborate with internal departments and healthcare providers on clinical and risk matters
• Support quality improvement initiatives through data analysis and actionable recommendations
• Carry out any additional responsibilities as required from time to time

• Matric / Senior Certificate
• Registered Nursing Diploma
• Valid registration with the South African Nursing Council (SANC)
• Certification in Claims and Forensic Risk Management
• Registration with the Association of Certified Fraud Examiners (ACFE SA)
• FAIS compliance or significant progress toward FAIS qualification (advantageous)

• Minimum of 4 years’ experience in provider utilisation and fraud management
• Demonstrated ability to lead and manage clinical teams
• Previous experience within a managed care or health insurance environment
• In-depth understanding of South Africa’s medical landscape, including relevant legislation and sector dynamics
• Excellent interpersonal skills with the ability to engage stakeholders, providers, clinicians, and members effectively
• Strong analytical, problem-solving, and decision-making skills with keen attention to detail
• High ethical standards and personal/professional integrity
• Ability to manage a multidisciplinary team proactively
• Excellent written and verbal communication skills
• Proficiency in Microsoft Office applications
• Solid understanding of evidence-based medicine and health economic principles
• Capable of managing multiple priorities and making sound clinical decisions under pressure
• Comprehensive understanding of medical benefit structures and healthcare product offerings

• Salary: negotiable.
• Our client is offering a highly competitive salary for this role based on experience.
  
• You can also visit the Hire Resolve website: hireresolve.us or email us your CV: financialcareers@hireresolve.za.com
• Alternatively, you can also contact me directly at kay-leen.dupreez@hireresolve.us
• When applying via email please use "Clinical Risk Manager" as the subject line