Head Of Strategic Risk Management at Discovery Limited

Key Purpose

To lead a team of professionals in developing and implementing managed care strategies and initiatives for Discovery Health-administered medical schemes and health insurance products that provide members with access to best possible benefits and healthcare services, highest quality of care and ensure the long-term affordability and sustainability of Discovery Health client medical schemes and health insurance products.

Areas of responsibility may include but not limited to:

Managed care

Develop and drive implementation of managed care strategies, initiatives and clinical policies across the following areas:

• Hospitals
• Healthcare professionals
• Medicines
• Medical and surgical devices
• Pathology services
• Radiology services
• Population health management and chronic disease programs
• Emergency medical services
• Oversee the development of medical scheme benefits and rules for Discovery Health-administered medical schemes and health insurance products that ensure access to best possible healthcare, market differentiation and cost efficiency

Lead and oversee contracting and commercial partnerships with healthcare providers including:

• Tariff negotiations
• New medicines and medical/surgical devices
• New facilities and services
• Health Technology Assessments (HTA)
• Pharmacy Benefit Management (PBM)
• Value-based Contracting (VBC) agreements
• Designated Service Providers (DSP)
• Network arrangements

Lead and oversee service and quality improvement initiatives including:

• Clinical and patient experience outcome tracking and monitoring
• Healthcare provider ratings, profiling and outlier management
• Lead and oversee fraud, waste and abuse initiatives and cost recovery including coding and billing audits and recoveries

Financial tracking, reporting and governance

• Track and monitor cost and utilisation trends across administered medical schemes
• Develop and implement appropriate managed care interventions to address increased cost and/or utilisation, access or quality issues that may arise from time-to-time
• Track and report on impact of managed care interventions
• Lead and oversee reporting and governance for client medical scheme executive offices and Boards of Trustees, and for Discovery Group-related governance incuding the Discovery Health Board and Executive Committee
• Participate in various internal governance fora in relation to managed care, medical scheme benefits, member experience, contributions etc.

Innovation

Develop innovations in managed care including:

• New products and services
• New delivery models
• New quality improvement initiatives
• New contracting and value-based care models
• New or refined benefits
• Participate in the Discovery Health R&D process in support of annual new product launch cycle

Provider and regulatory relations

Lead and oversee provider and health professional relationships incl.

• Professional societies and health professional groups
• Health professional and industry associations
• Key healthcare academics, specialists and opinion leaders
• Lead engagement with patient advocacy and healthcare civil society organisations
• Support engagement with main industry regulators e.g., Health Professions Council of South Africa (HPCSA); Council for Medical Schemes (CMS); National Department of Health (NDOH)

Client relationships

• Build and maintain relationships with executive and senior leaders of Discovery Health medical scheme clients and their advisors
• Support clients in relation to managed care and industry matters

Team and people leadership

• Build a team of high-performing, highly motivated professionals
• Create a fulfilling workplace that fosters professional growth and job satisfaction for all members of the team
• Identify and recruit top talent in accordance with the team needs and the overall managed care and business strategy
• Oversee professional and personal development of all members of the team, promoting ongoing personal learning, business and industry leadership
• Identify potential gaps in competency and/or performance and support team members in addressing these
• Proactively work on own personal and professional development, ensuring highest possible performance, mental health and resilience

Executive and business leadership

• Work collaboratively with colleagues across Discovery Health to ensure overall strategic and business objectives are met incl. CEO, CCO, COO, CIO, CDO, Chief Actuary and Chief Data Analytics Actuary, Head of Benefits Unit, Head of R&D, Head of People etc.
• Work collaboratively with colleagues across the Discovery Group to ensure that clients have access to best available services and expertise from across the Group incl. Vitality, marketing, employee benefits, systems

Personal Attributes and Skills

• Exceptional strategic ability, particularly in the context of health systems and managed care interventions in relation to health insurance
• Exceptional problem-solving and analytical ability; able to cope with highly complex and ambiguous problems on a day-to-day basis
• Exceptional communication ability (written and oral); able to prepare and present compelling executive-level documents and presentations on a routine basis
• Exceptional people leadership ability; able to lead and inspire a team of experienced professionals in solving complex problems and driving ongoing innovation
• Exceptional stakeholder engagement and negotiation ability

Education and Experience

• Advanced health-related and/or commercial under-graduate and post-graduate qualification e.g., MBCHB, BPharm, BSc, MSc, CA, Actuarial Science
• Qualified MD, MBA would be advantageous
• Managed care, health insurance, healthcare provider, and/or senior strategic management consulting experience in a top-tier consulting firm