Location: Centurion, Gauteng

Position Purpose: To lead and manage a team of professionals responsible for hospital pre-authorisations and/or case management, ensuring accurate, clinically appropriate, and cost-effective decision-making. The role ensures adherence to clinical guidelines, medical necessity criteria, and effective clinical risk management, while optimizing patient outcomes and resource utilization.

 Experience: Minimum of 2 to 3 years relevant managed care, health risk and clinical customer service within Medical Scheme Administration Industry or similar. Previous exposure in managing a Clinical team will be advantageous.

Qualifications:

• Nursing qualification with SANC registration/enrolment (mandatory)
• Strong knowledge of scheme rules, coding, and managed care protocols

Accountabilities:

Compliance and Risk Management

• Analyse and provide client specific and business reports
• Defined legal, statutory and regulatory compliance is appropriately implemented and maintained at the required standards for the team
• Implemented team operational risk and governance structures, measures and frameworks are monitored and necessary action is taken to address issues, when necessary

 Financial Management

• Manage expenses and costs and identify cost saving opportunities to support the department in achieving its financial goals and targets

Operating Model

• Ensure best quality work delivered by team in the execution of tasks
• Assist with implementation and maintenance of Standard Operations Procedures
• Investigate IT queries and escalate where required
• Implement team operational plans and manage that the defined delivery objectives are met through supporting, and being supported by other teams within and linked to the department / project
• Identify opportunities to improve the team’s core operational internal processes and internal supply chain
• Resolve team operational conflicts
• Ensure delivery targets/objectives are met and motivate the team to operate in a mutually supportive manner to achieve successful delivery

 Operational Implementation of Strategy

• Plan and implement daily, weekly and/or quarterly operational changes within the team to respond to important external influences
• Ensure relevant sections of the business plan are implemented in a manner that supports operational quality and meets the defined departmental priorities
• Communicate the relevant sections of the team operational plan to facilitate buy-in of the employees
• Ensure implementation of work plans in a way that maintains operational best practice and leads to continuous delivery improvement

 Operational Leadership

• Manage the operational performance of the team as per HR frameworks and policies to ensure delivery to agreed standards and objectives
• Provide appropriate staff development, coaching and mentoring and retain skilled and engaged employees within the team and company
• Support transformation through valuing diversity within the team and department
• Behave in alignment with the company values

Stakeholder Management

• Ensure appropriate, active and informative relationships with customers and relevant stakeholders are successfully maintained
• Address customer or stakeholder complaints in alignment with the policies and procedures and ensuring customer / stakeholder buy-in

Position Specific Outputs

Competency Requirements:

 Attribute

• Ownership: Make critical decisions based on what’s right for PHA – Owning operational decisions and knowing oneself
• Credibility: Lead with integrity and trust others as you would like to be trusted
• Living the values and being transparent
• Entrepreneurship: Take chances to continuously improve our customer’s experiences -Driving operational efficiencies
• Influence: Engage with Customers and colleagues to advance the organisation’s welfare -Making work happen
• Collaboration: Build work-related network and share knowledge with colleagues
• Building networks
• Knowledge and application of relevant legislation
• Knowledge and application of processes and procedures

Skill

• Computer Technology Skills
• Communication Skills
• Business Writing Skills
• Knowledge and application of clinical risk assessment
• Attention to Accuracy and Detail
• Problem Solving
• Numerical Ability
• Customer Focus
• Manage team and individual performance

Note: Company reserves the right to close the advert before specified closing date.