CLIENT
A top medical aid administrator with a strong managed care program for Optometry and Renal Dialysis (amongst other disease areas) is seeking candidates who either have strong OPTOMETRY or RENAL DIALYSIS subject matter expertise (two positions) coupled with strong benefits design optimization, risk management, contracting management, and regulatory compliance experience as well as strong industry stakeholder relationships.
Key Purpose
To manage strategic risk priorities with contracted specialty groups focusing on optometry and renal providers:
- To manage and oversee all aspects of optometry benefits, risk, and industry engagement across all schemes and plan options within the CLIENT and serve as the strategic and operational Subject Matter Expert (SME) on optometry, ensuring benefit design optimization, regulatory compliance, and sustainable utilization while maintaining strong industry relationships; AND/OR
- To manage, optimize, and oversee the full renal dialysis benefit, provider networks, risk exposure, and value-based care strategy across all schemes and plan types within CLIENT. And be responsible for designing and implementing sustainable dialysis care models, contracting frameworks, and operational processes that ensure optimal clinical outcomes, cost efficiency, and compliance with scheme rules and national health policy.
KEY REQUIREMENTS
Qualifications:
- Bachelor’s degree or equivalent in health sciences, optometry/Renal dialysis, business, or a related field.
- Postgraduate studies or certifications in healthcare management, risk management, or optometry or Renal Dialysis (advantageous).
Experience:
- Minimum 5-7 years in healthcare benefit design, network management, or managed care roles, with significant exposure to optometry / Renal
- Proven track record in relationship management with external healthcare providers and industry stakeholders within optometry / Renal
Technical Competencies:
- Deep understanding of optical benefit structures, coding systems, and reimbursement models.
- Knowledge of PMB processes and Ex Gratia protocols.
- Strong analytical skills for benefit optimization, utilization management, and financial impact assessments.
- Familiarity with claims processing, provider billing rules and system configuration requirements.
Behavioral Competencies:
- Strategic thinking and problem-solving ability.
- Strong interpersonal and communication skills to build trust with industry partners and internal teams.
- High attention to detail with commitment to accuracy and compliance.
- Leadership capability to drive cross-functional projects and influence scheme-wide decisions beyond the scope of the direct portfolio.
KEY RESPONSIBILITIES - OPTOMETRY
Key Account and Relationship Management:
- Act as the primary relationship manager between the CLIENT and external stakeholders in the optometry industry, including professional bodies, optical administrators, and individual optometrists.
- Maintain effective communication and partnership with industry representatives to ensure alignment with professional standards and practices.
Benefit Design and Strategy:
- Design, build, and steer optical benefits for new medical schemes joining the CLIENT and for new plan options for existing schemes.
- Provide strategic advice on benefit optimization to ensure competitiveness, member value, and cost-effectiveness.
Subject Matter Expertise (SME):
- Serve as the internal SME for all business areas requiring optometry input.
- Provide technical input into Prescribe Minimum Benefit (PMB) processes, Ex Gratia requests, and member or provider escalations.
Price File Management and Coding Updates:
- Ensure price files are updated three times per month in line with industry updates and scheme requirements.
- Oversee quarterly updates to industry coding and rules, ensuring accurate system configuration and operational readiness.
Contract Ownership and Risk Management:
- Act as contract owner for lower plan types, managing utilization, benefit structures, and associated risks in collaboration with Industry Optical Administrators.
- Monitor, analyze, and mitigate risks to ensure sustainability and value delivery to schemes and members.
Committee Leadership:
- Chair the CLIENTS Optical Benefit Review Committee for optical escalations, ensuring fair, evidence-based decisions aligned with scheme rules and industry standards.
KEY RESPONSIBILITIES IN RENAL
Strategic Network Design and Management
- Lead the design, development, and implementation of dialysis provider networks, including the CLIENT VBC (Value-Based Care) networks, and CLIENTS Dialysis Network).
- Oversee network adequacy, capacity planning, and geographical coverage to ensure equitable access for all members.
- Develop and refine co-payment structures, direct-to-member payment rules, and in-hospital vs out-of-hospital funding strategies to drive appropriate utilization and cost containment.
Contracting and Value-Based Agreements
- Design, negotiate, and implement dialysis provider contracts, including: Fee-for-service agreements
- Value-based care models with outcome-linked reimbursements
- Capitated or bundled payment arrangements where appropriate
- Define pricing structures ensuring sustainability and alignment with plan benefits and industry standards.
Risk Management and Benefit Sustainability
- Analyse dialysis utilisation trends, admission rates, and cost drivers to inform scheme risk management strategies.
- Develop mitigation measures, such as network restrictions, benefit limits, and clinical entry criteria, to manage financial risk without compromising clinical care.
- Implement data-driven frameworks to monitor provider performance, patient outcomes, and cost effectiveness.
Clinical and Operational Protocols
- Collaborate with clinical teams to define dialysis care pathways, treatment authorisation protocols, and quality indicators.
- Oversee updates to dialysis-related price files, procedure codes, and benefit rules to ensure accuracy and operational readiness.
- Provide SME input into system configuration for benefit rules, claim edits, and authorisation workflows.
Stakeholder and Relationship Management
- Act as the primary relationship manager for dialysis providers, industry stakeholders, and internal departments requiring renal expertise.
- Lead engagements with external providers to align operational processes, data submission standards, and network compliance.
- Facilitate internal education on renal benefit structures and policy changes.
Project Leadership and Future Care Models
- Lead strategic projects to transition renal dialysis benefits to advanced managed care models incorporating: Risk-sharing arrangements
- Integrated chronic disease management
- Future readiness for National Health Insurance (NHI) alignment
- Drive proposals and implementation plans for new models, such as: Capitation or partial capitation models
- Virtual care integration for dialysis patients
- Holistic chronic kidney disease (CKD) management pathways, including pre-dialysis interventions
Governance and Compliance
- Ensure dialysis network and benefit models comply with regulatory frameworks and scheme rules.
- Lead periodic reviews of dialysis policies to align with updated clinical guidelines and scheme strategic objectives.
