Requirements:

• Grade 12 / Matric is relevant
• General Nursing Diploma or Degree
• Must be registered with SANC (South African Nursing Council) as a Registered / Professional Nurse
• A minimum of 3 years’ experience in a managed care/case management environment
• A minimum of 3 years’ clinical experience within a private hospital is essential (ICU and theatre experience is advantageous) 
• Prior leadership experience is advantageous
• Clinical Auditing experience is advantageous
• Good understanding of the Medical Scheme industry 
• Proficient in Microsoft Office

Responsibilities:

• Lead and supervise the Case Management and Clinical Claims Auditing teams, ensuring achievement of key performance indicators (KPIs) and service delivery 
  standards.
• Ensure compliance with all company HR policies and procedures.
• Provide ongoing training, guidance, and communication to staff regarding benefits, tariffs, scheme rules, and organisational policies and procedures. 
• Support the resolution of complex and escalated case management and clinical audit queries. 
• Manage and investigate complaints received from the Council for Medical Schemes (CMS) and liaise with Fund Managers to ensure effective resolution. 
• Monitor, analyse, and report on weekly operational and performance metrics, implementing corrective actions and continuous improvement initiatives where required. 
• Assist Fund Managers with the compilation of information and preparation of reports and presentations for meetings and stakeholder engagements. 
• Review and analyse workflow processes to identify efficiencies, enhance productivity, and ensure process relevance and effectiveness. 
• Ensure all operational, audit, and performance reports are reviewed, validated, and appropriately actioned within agreed timelines.