About the position
Job purpose:
- To provide leadership and strategic direction, innovation, and the management necessary to identify, evaluate, mitigate, and monitor the Scheme's strategic and operational risks including fraud, waste, and abuse, and report findings to the Principal Officer (PO) and the relevant Board committees.
Strategy, Planning, and Execution
- Participate in the development and review of the Scheme's strategic plan
- Develop and implement a risk management framework for the Scheme
- Build a tight link between risk management and business-planning processes
- Facilitate a corporate-level discussion of risk preference, focusing on what risk choices will most likely deliver economic profit for the Scheme
- Use risk analytics to inform investment and strategic decisions
- Ensure that risk is kept at the forefront of the governance process and embedded within the Scheme
- Develop and implement Fraud, Waste, and Abuse (FWA) investigative strategies, policies, and procedures
Enterprise Risk Management
- Establish the enterprise risk management architecture for the Scheme
- Manage risk processes to ensure an integrated approach, operational efficiency, effectiveness, and the application of best practice
- Assess risks and measure the Scheme's exposure to them
- Support the Board committees in the implementation, review, and approval of the enterprise-wide risk governance framework including the Scheme's risk culture, risk appetite, and risk limits
- Monitor on an ongoing basis the risk-taking activities and risk exposures to ensure they are in line with the board-approved risk appetite, risk limits, and corresponding capital or liquidity needs
- Influence and, when necessary, challenge material risk decisions
- Recommend and implement control mechanisms to minimize risk exposure for the Scheme
- Develop and maintain the various risk registers including strategic and operational risks
- Develop risk mitigation strategies and action plans for implementation
- Establish and quantify 'risk appetite,' and offer proactive and reactive guidance on all areas of risk management
- Manage projects and initiatives as required
Risk and Fraud Investigations
- Identify potential areas of risk, clinical and non-clinical, and prepare a risk audit plan to address risks
- Analyze utilization data and reports received from the relevant departments in order to confirm the accuracy and ensure potential risks are identified and addressed
- Support the development and implementation of an audit plan in conjunction with the Executive team
- Perform relevant audits, prepare reports, and make recommendations to the executive team and the Audit Committee
- Investigate fraudulent and wasteful transactions:
- Proactively investigate potential fraud, waste, and abuse by members, providers, and other stakeholders
- Investigate patterns in claims and admission data
- Conduct interviews or issue correspondence to determine settlements, objections, or reviews
- Store documentation and evidence, and prepare a summary of findings
- Conduct investigation-related training with relevant stakeholders
- Lead the development of solutions with high complexity and risk
Legal Support
- Support legal proceedings as needed, including testifying in court or working with law enforcement personnel/ agencies to prepare cases for civil or criminal actions
- Collaborate with the legal team to negotiate settlement agreements and/or apply for litigations to resolve disputes
- Lead the process of recovery of overpayments and accounting of savings related to fraudulent and/or abusive billing
- Maintain current knowledge of all standard billing, coding practices, relevant laws, regulations, and standards
Reporting
- Prepare monthly, quarterly, and annual reports for the PO with relevant management information that informs decision-making by the executive team
- Report on the Scheme's risk registers
- Prepare and present risk reports to the Risk and Audit Committees
- Report findings and recommendations on fraud investigations to EXCO and the relevant sub-committees
Cross-functional Coordination
- Coordinate with Executives across departments to create cross-functional teams comprising different expertise and backgrounds to work towards a common goal in task teams or projects
Leverage diverse skills and experience by bringing people from different pasrts of the Scheme to produce innovative solutions
Build cross-functional collaboration so that the Scheme can become more competitive in the market with greater business agility
- Use cross-functional teams to tackle silo mentality and bridge the gap between team members and thus increase organisational efficiency
- Manage projects involving cross-functional teams and leverage diversity and communication efficiencies
Governance, risk, and compliance (GRC)
- Ensure the scheme's risk management policies and strategies are in compliance with applicable legislation, standards, policies, procedures, and strategic imperatives of the Scheme
- Coordinate risk management policy updates with relevant stakeholders, including Audit Committee
- Monitor control processes for operatonal and other risks
Minimum Qualifications / certifications:-
- B degree/ Higher Diploma in Risk Management/ Auditing/ Health Sciences/ Law OR equivalent qualification with NQF Level 7
- Postgraduate Qualification in Risk Management will be added advantage-
- Membership with a Risk Management-related professional body
Prior experience required:
- Minimum of 5-7 years' experience in Risk Management, Cross-functional Coordination, and Project Management
Desired Skills:
- relevant degree
- Post graduate qualification in Risk management would be an added advantage
- 5-7 years experience in Risk Management and Project management