GOVERNMENT EMPLOYEES MEDICAL SCHEME (GEMS) VACANCIES

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SENIOR MANAGER: CLINICAL RISK MANAGEMENT
Type: Permanent 
Salary: The total remuneration package will be based on qualifications and experience.
The position of Senior Manager:  Clinical Risk Management is vacant. The Senior Manager:  Clinical Risk Management will report directly to the Chief Healthcare Officer and forms part of the Healthcare Division. The position is based in Head Office in Pretoria.
 
The total remuneration package for this position is negotiable based on qualifications and experience.
 
The Senior Manager:  Clinical Risk Management will be required to provide support to the Chief Healthcare Officer through the implementation of the following Key Performance Areas (KPAs):

• Manage, setup and drive the Clinical Risk and Medicine Benefits management programme internally and externally (SPNs).
• Manage service providers to ensure Disease Risk Management (DRM) programmes are effectively and efficiently managed.
• Manage service providers to ensure that Pharmaceutical Benefits are utilised effectively and efficiently by members.
• Manage, drive and setup a case management programme to drive In-hospital case management, early discharge planning and Sub- acute/ Stepdown programmes.
• Lead and mentor staff within the Clinical Risk Management (CRM) functional unit.
• Maintain relationships within the healthcare industry and stay abreast of new developments that impact Clinical risk management.
• Required to assist and provide support with the review of the Scheme’s policies, protocols and formularies from a clinical and financial position.
• Provide clinical risk management support to the Healthcare Management Division.
• Ensure that all risk areas applicable to Healthcare Management are identified, communicated and strategies put in place to mitigate risk.
• Manage the process for development and maintenance of Clinical Risk and Medicine benefits management standard operating procedures and policies.
• Drive Clinical Risk and Medicine Management efficiency to deliver clinically approved and evidence-based quality outcomes.
• Direct all Clinical risk and Medicine Benefits Management activities to ensure successful attainment of strategic objectives.
• Ensure an efficient and well-functioning Clinical risk and Medicine Benefits Management platform.
• Contribute to targeted research into local and international clinical guidelines and funding policies for Clinical risk and Medicine Benefits management.
• Evaluate current cost drivers, trends and compare with those of local and international sources for best practice.
• Monitor and drive all activities managed care activities related to Clinical Risk and Medicine management.
• Review and provide expertise on new Health Technology assessments for Clinical risk management.
• Develop and maintain adequate knowledge of data handling and interpretation of information translating interventions.
• Provide Clinical Risk and Medicine management technical support when the Scheme is having difficulties in defined areas, working closely with the team to sort out any challenges.
• Provide clinical risk management support to the Healthcare Management Division.
• Ensure that all risk areas applicable to Healthcare Management are identified, communicated and strategies put in place to mitigate risk.
• Manage the process for development and maintenance of Clinical Risk and Medicine benefits management standard operating procedures and policies.
• Drive Clinical Risk and Medicine Management efficiency to deliver clinically approved and evidence-based quality outcomes.
• Direct all Clinical risk and Medicine Benefits Management activities to ensure successful attainment of strategic objectives.
• Ensure an efficient and well-functioning Clinical risk and Medicine Benefits Management   platform.
• Contribute to targeted research into local and international clinical guidelines and funding policies for Clinical risk and Medicine Benefits management.
• Evaluate current cost drivers, trends and compare with those of local and international sources for best practice.
• Monitor and drive all activities managed care activities related to Clinical Risk and Medicine management.
• Review and provide expertise on new Health Technology assessments for Clinical risk management. 
• Develop and maintain adequate knowledge of data handling and interpretation of information translating interventions.
• Provide Clinical Risk and Medicine management technical support when the Scheme is having difficulties in defined areas, working closely with the team to sort out any challenges.
• Review, revert and ensure all CMS circulars are responded too and timeously implemented.
• Review and maintain and updated PMB and CDL lists.
• Support the Scheme’s Expert Advisor Platforms.
• Provide input and support to the clinical committees, external advisory panel and other committees as and when required.
• Assist with all ad-hoc requests on any clinical and disease risk management matters.
• Participate in interdisciplinary committees within the Scheme.
• Participates in clinical projects/studies and interdisciplinary meetings as required.
• Support Scheme’s product development and benefit design activities.
• Manage, people, processes and system internally and externally (SPNs) staff where necessary who are sub-ordinates.
• Ensure compliance to CMS regulations.

 
Qualifications, skills and competencies requirements are: 

• Minimum 3-year degree or diploma in Clinical Sciences (medical/ nursing/ physiotherapy/psychology etc.).
• A Bachelor of Pharmacy degree will be advantageous.
• Minimum 8 years work experience in the medical aid industry.
• Minimum 4 years as Manager/Supervisor in the healthcare funding/ medical Scheme industry.
• Experience in medicine pricing, reimbursement of pharmaceutical services and managed care processes related to pharmaceutical benefits management is essential.
• Experience in Clinical Risk Management and Pharmaceutical Benefits Management
• Product Development and Benefit Design Experience
• Managed Care Experience
• Sound Clinical Knowledge of hospital medical practice across all disciplines and their therapeutic modalities.
• Experience in Clinical analytics.
• Sound qualitative and quantitative analytical skills.
• Must be in possession of a valid driver’s license and own vehicle and be willing to travel at short notice.
• A good understanding all coding (Nappi, Tariffs, ICD10, CPT4, UPFS and more).
• A good understanding of managed care processes.
• A good understanding of Clinical Risk and Medicine Benefits Management.
• A good understanding of the Medical Schemes Act, Pharmacy Act, Medicines and Related Substances Act etc.
• Strong Analytical, problem-solving ability and administrative skills.
• Strong verbal and written communication skills.
• The ability to conduct research using a variety of academic and market-related resources.
• Good organisational ability and able to meet tight deadlines.
• Accuracy and Attention to detail.
• Must be able to work in a team.

 
 
All external candidates, please apply via Career Junction using the following link :
 https://www.careerjunction.co.za/companies/35144/government-employees-medical-scheme
 
The closing date for applications is 17 April 2023. Should you not hear from us by 31 July 2023, please consider your application unsuccessful. 
 
*** GEMS employs people with the highest level of integrity – submission to the appropriate pre-employment assessment is obligatory to be considered for the position.
*** Kindly note that the information provided on application of the position may be shared with a third party for vetting purposes and will be stored by GEMS for a period of 5 years.
*** Kindly note that information is required for Employment Equity Purposes and information gathered is strictly used according to the intended purpose of collection, unless there is a legal need or permission is granted from the applicant themselves to make use of it for other purpose
*** Should you wish to have your information removed from the GEMS database, kindly send a request in writing to jobs@gems.gov.za.
*** GEMS adopts a hybrid work model
***GEMS is guided by the principles of employment equity. Preference will be given to groups who are underrepresented in accordance with GEMS employment equity plan.
 
 
 
 

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SPECIALIST: BUSINESS OPTIMIZATION (X2)
Type: Permanent 
Salary: The total remuneration package will be based on qualifications and experience.
 
The positions of Specialist: Business Optimization are vacant. The Specialist: Business Optimization will report directly to the Senior Manager: Business Optimization and forms part of the Office of the Chief Operations Officer division. The position is based at Head Office in Pretoria.
The remuneration package for this position is negotiable based on qualifications and experience.
 
The Specialist: Business Optimization will be required to provide support to the Senior Manager: Business Optimization through the implementation of the following Key Performance Areas (KPAs):

• Business process engineering (Identifying, rethinking, and optimising business processes) while driving business process integration across the full business value chain
• To assist in the development and implementation of a continuous improvement framework and strategy 
• To promote and deliver service improvement activities across the business through employing process improvement methodologies and the application of innovative thinking (incl. delivery of business transformation programmes)
• Collaboration with stakeholders regarding the strategic intent of Business Units, alignment of the architectural landscape for benchmarked practices to ensure effective and efficient business value streams, and integrating processes, people, and technology optimally by interactively analysing, designing, recommending and implementing innovative and cost-effective business processes.
• Define business problems and needs while considering process efficiency, cost-effectiveness, risk, compliance, local legislation, internal user experience (UX) and member experience (CX).

 
Qualification requirements are:

• Degree/Professional qualifications at NQF Level 6 in Business Management, Engineering, Operation Management, Clinical Sciences or similar
• A relevant post graduate qualification will serve an advantage
• Must have at least 3-5 years relevant functional experience in a Financial Services, Healthcare/Medical Aid or related Industry inclusive but not limited to Managed Care Services and Administration Management
• Scientific methodologies associated with efficiency improvements and Total Quality Management, i.e. Lean Six Sigma methodologies, Agile method, Systems thinking, Process Modelling, Customer journeys and Value Stream Mapping
• Understanding of Health Care Technology solutions
• Business process analysis, design and implementation skills
• Project and Programme Management skills 
• Organizational Change Management skills 
• Excellent people management and leadership abilities
• Superior communication, facilitation, and consensus-building skills
• Demonstrated relationship-building skills, with a superior ability to make things happen using positive influence
• A ‘completer-finisher’ taking accountability for ideas from inception to delivery, in an environment that requires robust metrics to confirm success.
• Organizational awareness with an understanding of how to engage the organization to get things done
• Strong problem-solving skills; comfortable tackling complex problems and breaking these down into manageable pieces
• Superior multi-tasking skills and the ability to work in a fast-paced, often deadline-oriented, and dynamic environment
• Conceptual and practical thinking and implementation skills
• Research, analysis and judgment skills
• Proficient in the use of Microsoft Office, including Project, Visio, Word, Excel, Outlook, and PowerPoint 

 
 
All external candidates, please apply via Career Junction using the following link: https://www.careerjunction.co.za/companies/35144/government-employees-medical-scheme
 
The closing date for applications is 17 April 2023. Should you not hear from us by 30 June 2023, please consider your application unsuccessful. 
 
*** GEMS employs people with the highest level of integrity – submission to the appropriate pre-employment assessment is obligatory to be considered for the position.
*** Kindly note that the information provided on application of the position may be shared with a third party for vetting purposes and will be stored by GEMS for a period of 5 years.
*** Kindly note that information is required for Employment Equity Purposes and information gathered is strictly used according to the intended purpose of collection, unless there is a legal need or permission is granted from the applicant themselves to make use of it for other purpose
*** Should you wish to have your information removed from the GEMS database, kindly send a request in writing to jobs@gems.gov.za.
*** GEMS adopts a hybrid work model
***GEMS is guided by the principles of employment equity. Preference will be given to groups who are underrepresented in accordance with GEMS employment equity plan.

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SPECIALIST: INTERNAL FORENSIC SPECIALIST
Type: Permanent 
Salary: The total remuneration package will be based on qualifications and experience.
 
The position of Internal Forensic Specialist is vacant: The Internal Forensic Specialist will report directly to the Senior Manager Internal Forensic Investigation and forms part of Internal Audit Division of the Scheme based in Pretoria.

The total remuneration package will be market related and is negotiable, based on qualifications and experience.

The Internal Forensic Specialist will be required to deliver independent and integrated forensic investigations and fraud risk management activities to support the Senior Manager Internal Forensic Investigations in executing the following functions: 


Key Performance Areas (KPAs):.

•   Conduct forensic investigations from start to finish;
• Conduct interviews, compile and review investigation reports; 
• Collect, process, document and analyse all evidence during the investigations / in support of disciplinary proceedings as defined in the project plan;
• Preparation of dockets for criminal and civil proceedings;
• Draft charges against employees and / or compiling case dockets for criminal prosecution; 
•  Assist in the implementation and control strategies for fraud prevention plan; 
• Assist with the development of the fraud risk management training programme and identification of high risk areas; 
• Conduct fraud risk assessments, report findings and/or deviations and assist in implementing controls; 
• Draft fraud risk management and investigation reports and  report closure and presentation of findings to Stakeholders; and 
• Assist with development and conducting Scheme wide training to create fraud awareness.

 
Qualification, skills and competencies requirements are:

• Diploma/Degree in Legal/ Finance as per FSCA approved qualifications list.  
• Successfully completed the International CFE Examination (NQF level 6); 
• National Diploma (NQF level 6) / Degree Forensics, Law, Accounting, Forensic Science and Technology or similar;
• Relevant certification will be advantageous;
• 3-5 years (functional 5 years and 3 managerial level) in forensic investigations and fraud risk management; 
• Experience in collection and presentation of evidence at Scheme level, criminal, civil and labour court;
•  Ability to run forensic assignments, draft affidavits, write reports and prepare dockets for criminal and civil proceedings; 
• Experience in fraud risk management prevention and detection assignments;
• A team player with an investigative mindset; 
• Strong analytical and problem-solving skills; 
• Excellent command of spoken and written English; and 
• Willingness to travel on assignments when required.

 
Behavioural Competencies are:

• Diploma/Degree in Legal/ Finance as per FSCA approved qualifications list.  
• Have excellent written and verbal communication and interpersonal skills;
• Excellent ability to problem solving with strong analytical skills;
• Strong knowledge of financial reporting; 
• Have the ability to analyse data and provide recommendations; 
• Strong organisational and mathematical skills;
• Ability to maintain confidential information and exercise discretion and tact; 
• High level of integrity and excellence;
• Excellent attention to detail;
• Have the ability to work well as part of a team;
• Have a diligent work ethic;
• Have excellent written and verbal communication and interpersonal skills
• Excellent ability to problem solving with strong analytical skills;
• Strong knowledge of financial reporting; 
• Have the ability to analyse data and provide recommendations; 
• Strong organisational and mathematical skills;
• Ability to maintain confidential information and exercise discretion and tact; and
• Presentation and training skills. 

 
 
Desirable 
Have an understanding of medical schemes industry or financial services industry.
All external candidates, please apply via Career Junction using the following link:  https://www.careerjunction.co.za/companies/35144/government-employees-medical-scheme
 
The closing date for applications is 19 April 2023. Should you not hear from us by 30 June 2023, please consider your application unsuccessful. 
 
*** GEMS employs people with the highest level of integrity – submission to the appropriate pre-employment assessment is obligatory to be considered for the position.
*** Kindly note that the information provided on application of the position may be shared with a third party for vetting purposes and will be stored by GEMS for a period of 5 years.
*** Kindly note that information is required for Employment Equity Purposes and information gathered is strictly used according to the intended purpose of collection, unless there is a legal need or permission is granted from the applicant themselves to make use of it for other purpose
*** Should you wish to have your information removed from the GEMS database, kindly send a request in writing to jobs@gems.gov.za.
*** GEMS adopts a hybrid work model
***GEMS is guided by the principles of employment equity. Preference will be given to groups who are underrepresented in accordance with GEMS employment equity plan.