The position of Senior Manager:  Clinical Risk Management is vacant. The Senior Manager:  Clinical Risk Management will report directly to the Chief Healthcare Officer and forms part of the Healthcare Division. The position is based in Head Office in Pretoria.

The total remuneration package for this position is negotiable based on qualifications and experience.

The Senior Manager:  Clinical Risk Management will be required to provide support to the Chief Healthcare Officer through the implementation of the following Key Performance Areas (KPAs):

• Manage, setup and drive the Clinical Risk and Medicine Benefits management programme internally and externally (SPNs).
• Manage service providers to ensure Disease Risk Management (DRM) programmes are effectively and efficiently managed.
• Manage service providers to ensure that Pharmaceutical Benefits are utilised effectively and efficiently by members.
• Manage, drive and setup a case management programme to drive In-hospital case management, early discharge planning and Sub- acute/ Stepdown programmes.
• Lead and mentor staff within the Clinical Risk Management (CRM) functional unit.
• Maintain relationships within the healthcare industry and stay abreast of new developments that impact Clinical risk management.
• Required to assist and provide support with the review of the Scheme’s policies, protocols and formularies from a clinical and financial position.
• Provide clinical risk management support to the Healthcare Management Division.
• Ensure that all risk areas applicable to Healthcare Management are identified, communicated and strategies put in place to mitigate risk.
• Manage the process for development and maintenance of Clinical Risk and Medicine benefits management standard operating procedures and policies.
• Drive Clinical Risk and Medicine Management efficiency to deliver clinically approved and evidence-based quality outcomes.
• Direct all Clinical risk and Medicine Benefits Management activities to ensure successful attainment of strategic objectives.
• Ensure an efficient and well-functioning Clinical risk and Medicine Benefits Management platform.
• Contribute to targeted research into local and international clinical guidelines and funding policies for Clinical risk and Medicine Benefits management.
• Evaluate current cost drivers, trends and compare with those of local and international sources for best practice.
• Monitor and drive all activities managed care activities related to Clinical Risk and Medicine management.
• Review and provide expertise on new Health Technology assessments for Clinical risk management.
• Develop and maintain adequate knowledge of data handling and interpretation of information translating interventions.
• Provide Clinical Risk and Medicine management technical support when the Scheme is having difficulties in defined areas, working closely with the team to sort out any challenges.
• Provide clinical risk management support to the Healthcare Management Division.
• Ensure that all risk areas applicable to Healthcare Management are identified, communicated and strategies put in place to mitigate risk.
• Manage the process for development and maintenance of Clinical Risk and Medicine benefits management standard operating procedures and policies.
• Drive Clinical Risk and Medicine Management efficiency to deliver clinically approved and evidence-based quality outcomes.
• Direct all Clinical risk and Medicine Benefits Management activities to ensure successful attainment of strategic objectives.
• Ensure an efficient and well-functioning Clinical risk and Medicine Benefits Management   platform.
• Contribute to targeted research into local and international clinical guidelines and funding policies for Clinical risk and Medicine Benefits management.
• Evaluate current cost drivers, trends and compare with those of local and international sources for best practice.
• Monitor and drive all activities managed care activities related to Clinical Risk and Medicine management.
• Review and provide expertise on new Health Technology assessments for Clinical risk management. 
• Develop and maintain adequate knowledge of data handling and interpretation of information translating interventions.
• Provide Clinical Risk and Medicine management technical support when the Scheme is having difficulties in defined areas, working closely with the team to sort out any challenges.
• Review, revert and ensure all CMS circulars are responded too and timeously implemented.
• Review and maintain and updated PMB and CDL lists.
• Support the Scheme’s Expert Advisor Platforms.
• Provide input and support to the clinical committees, external advisory panel and other committees as and when required.
• Assist with all ad-hoc requests on any clinical and disease risk management matters.
• Participate in interdisciplinary committees within the Scheme.
• Participates in clinical projects/studies and interdisciplinary meetings as required.
• Support Scheme’s product development and benefit design activities.
• Manage, people, processes and system internally and externally (SPNs) staff where necessary who are sub-ordinates.
• Ensure compliance to CMS regulations.

Qualifications, skills and competencies requirements are: 

• Minimum 3-year degree or diploma in Clinical Sciences (medical/ nursing/ physiotherapy/psychology etc.).
• A Bachelor of Pharmacy degree will be advantageous.
• Minimum 8 years work experience in the medical aid industry.
• Minimum 4 years as Manager/Supervisor in the healthcare funding/ medical Scheme industry.
• Experience in medicine pricing, reimbursement of pharmaceutical services and managed care processes related to pharmaceutical benefits management is essential.
• Experience in Clinical Risk Management and Pharmaceutical Benefits Management
• Product Development and Benefit Design Experience
• Managed Care Experience
• Sound Clinical Knowledge of hospital medical practice across all disciplines and their therapeutic modalities.
• Experience in Clinical analytics.
• Sound qualitative and quantitative analytical skills.
• Must be in possession of a valid driver’s license and own vehicle and be willing to travel at short notice.
• A good understanding all coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more).
• A good understanding of managed care processes.
• A good understanding of Clinical Risk and Medicine Benefits Management.
• A good understanding of the Medical Schemes Act, Pharmacy Act, Medicines and Related Substances Act etc.
• Strong Analytical, problem-solving ability and administrative skills.
• Strong verbal and written communication skills.
• The ability to conduct research using a variety of academic and market-related resources.
• Good organisational ability and able to meet tight deadlines.
• Accuracy and Attention to detail.
• Must be able to work in a team.

All external candidates, please apply via Career Junction using the following link :

https://www.careerjunction.co.za/companies/35144/government-employees-medical-scheme

The closing date for applications is 17 April 2023. Should you not hear from us by 31 July 2023, please consider your application unsuccessful. 

*** GEMS employs people with the highest level of integrity – submission to the appropriate pre-employment assessment is obligatory to be considered for the position.

*** Kindly note that the information provided on application of the position may be shared with a third party for vetting purposes and will be stored by GEMS for a period of 5 years.

*** Kindly note that information is required for Employment Equity Purposes and information gathered is strictly used according to the intended purpose of collection, unless there is a legal need or permission is granted from the applicant themselves to make use of it for other purpose

*** Should you wish to have your information removed from the GEMS database, kindly send a request in writing to jobs@gems.gov.za.

*** GEMS adopts a hybrid work model

***GEMS is guided by the principles of employment equity. Preference will be given to groups who are underrepresented in accordance with GEMS employment equity plan.