South Africa

Senior Manager Managed Care

Company Medihelp
Reference # Cicelia Strauss
Published 08/06/2021
Contract Type Permanent
Salary Market Related
Location Pretoria, Gauteng, South Africa
The position was added to the new structure
Job Functions Administration,Clinical
Industries Insurance

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; and

Ensure pre-authorisations and cases are managed in accordance with system-driven protocols and algorithms.

Efficient management of clinical benefit management, including hospital management, oncology, specialised radiology, clinical audit, hospital enquiries, medicine

management, Pharmaceutical Benefit management and provider administration.

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; and

Maintain all healthcare providers’ details.

Manage cases of non-declaration on new membership applications

Manage clinical coding enquiries / changes and out of protocol applications (e.g. oncology)

Oversee the management of high-cost admissions and high-cost cases, hospital audit and hospital enquiries

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 unit’s 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.

Four-year (or more) clinical degree.

Eight years’ relevant experience, of which two years must be in managed care and four years on management level.

Must possess knowledge of the following:

The Medical Schemes Act and Regulations;

FAIS, TCF and POPI Acts;

Managed healthcare programmes, processes and systems;

Coding (ICD-10, PMB, NAPPI, CPT and RPL); and

Industry practices and trends.

Computer literate in MS Office (advanced).

Must possess the following skills:

Business insight;

Decision making;

Negotiation skills;

Technical knowledge and professional skills;

Presentation and report writing skills;

Good interpersonal relations and customer focus;

Leadership skills;

Able to function well under pressure; and

Organising and coordination skills.
Job Closing Date 14/06/2021
Share on
Last Updated: 12 days ago []
Webserver: SkillsMap (NLBB)