Head Medical Service and Provider Management

Job DescriptionThe Job at a GlanceReporting into the Managing Executive: Medical and Pensions Management, the incumbent will provide strategic leadership and clinical governance for medical services within the claims value chain, ensuring accurate medical liability adjudication, effective provider management, cost optimisation, optimal healthcare utilisation, and high-quality, cost-effective patient outcomes. They will drive excellence in provider relations, hospital utilisation, and medical claims processing. The incumbent will also be responsible for organising, coordinating, and supervising the department to achieve greater functional efficiency and for ensuring the continuous improvement of policies and strategic direction in line with best practice. They will also develop, establish, and manage key support networks and provide medical support to stakeholders. The incumbent will manage projects and programmes, and ensure the provision of medical advice and training to all stakeholders of Rand Mutual Assurance.What Will You Do?Clinical Leadership & GovernanceProvide strategic oversight of the Medical Advisory functionAct as the final decision-maker on complex and high-risk medical casesEnsure consistent, evidence-based medical liability adjudication aligned with applicable legislatureLead clinical governance, protocols, and multidisciplinary case reviewsMedical Claims & Invoice ManagementOversee the end-to-end medical invoice adjudication, approval, and payment processEnsure accuracy, compliance, and efficiency in claims processingImplement controls to mitigate fraud, waste, and abuseDrive automation and continuous improvement in claims adjudication systemsHospital Utilisation ManagementLead hospital case management teams responsible for:Level of Care (LOC)Length of Stay (LOS)Preauthorisation and concurrent reviewsEnsure appropriate care pathways and timely referrals to subacute Rehabilitation and Return-to-Work programmesOptimise clinical outcomes while managing healthcare costsProvider Management & Network DevelopmentDevelop and manage a diverse, high-performing healthcare provider network.Strengthen provider relationships and enhance customer satisfactionExpand access to care through strategic provider onboardingMonitor provider performance, quality, and cost efficiencyStrategy, Compliance & Stakeholder EngagementAlign medical services with organisational strategy and regulatory requirements.Collaborate with internal and external stakeholders, including regulators and healthcare providers Support governance, risk management, and audit processes Job RequirementsWhat Will You Bring to the Table?MBChB is essentialKnowledge of Claims Management PoliciesRegistration with SA Health Professions Council as a Medical professionalOccupational Health Professional Diploma (DOH) is essentialPostgraduate Qualification in Public Health Management or MBAAt least 10 years of relevant clinical experienceAt least 5 years senior management experience in medical insurance, occupational health and/or compensation environmentProven experience in medical claims adjudication (insurance or compensation environment)Hospital utilisation managementRehabilitation and return to work frameworksMedico-legal assessment and impairment evaluation