Head Medical Service and Provider Management, Johannesburg

The Job at a Glance

Reporting 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 & Governance

• Provide strategic oversight of the Medical Advisory function
• Act as the final decision-maker on complex and high-risk medical cases
• Ensure consistent, evidence-based medical liability adjudication aligned with applicable legislature
• Lead clinical governance, protocols, and multidisciplinary case reviews

Medical Claims & Invoice Management

• Oversee the end-to-end medical invoice adjudication, approval, and payment process
• Ensure accuracy, compliance, and efficiency in claims processing
• Implement controls to mitigate fraud, waste, and abuse
• Drive automation and continuous improvement in claims adjudication systems

Hospital Utilisation Management

• Lead hospital case management teams responsible for:
• Level of Care (LOC)
• Length of Stay (LOS)
• Preauthorisation and concurrent reviews
• Ensure appropriate care pathways and timely referrals to subacute Rehabilitation and Return-to-Work programmes
• Optimise clinical outcomes while managing healthcare costs

Provider Management & Network Development

• Develop and manage a diverse, high-performing healthcare provider network.
• Strengthen provider relationships and enhance customer satisfaction
• Expand access to care through strategic provider onboarding
• Monitor provider performance, quality, and cost efficiency

Strategy, Compliance & Stakeholder Engagement

• Align 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