Medical Aid Operation Manager jobs

Company Description

About Kaelo
Kaelo provides essential healthcare solutions ensuring the physical and psychosocial wellbeing of all South Africans towards lasting social change. Kaelo meets the Healthcare needs of Corporate and Retail clients across South Africa – products offerings include Medical Insurance, Medical Aid, Gap Insurance, Kaelo Money and employee assistance programmes.

Job Description

We are seeking an experienced and results-driven Clinical Risk and Fraud, Waste & Abuse (FWA) Manager to join our Clinical Operations team.

This is an exciting opportunity for a passionate healthcare professional who thrives on identifying risks, solving complex problems, and implementing practical solutions that improve patient outcomes and protect organizational resources. The successful candidate will play a pivotal role in strengthening clinical governance, enhancing quality of care, driving patient safety initiatives, and leading the organization's fraud, waste and abuse prevention programme.

If you are a highly analytical, action-oriented leader with a strong sense of urgency and a track record of delivering measurable outcomes, we would like to hear from you.

record of delivering measurable outcomes, we would like to hear from you.

The Opportunity

Reporting to the Head of Clinical Operations, you will lead the organization's clinical risk management, quality assurance, patient safety, and healthcare integrity programmes. You will be responsible for identifying, assessing, mitigating and monitoring risks across clinical, operational, regulatory and financial environments while ensuring compliance with applicable legislation, governance standards and organizational policies.

You will work closely with multidisciplinary stakeholders to investigate incidents, identify root causes, implement corrective actions, improve quality outcomes, and strengthen fraud prevention controls.

This is a hands-on role requiring someone who can move beyond analysis and recommendations to drive implementation and deliver sustainable improvements.

Key Responsibilities

Clinical Risk and Patient Safety

• Lead the development and implementation of clinical risk management frameworks and patient safety initiatives.
• Conduct risk assessments and identify emerging clinical and operational risks.
• Investigate adverse events, complaints, incidents and near misses.
• Facilitate root cause analyses and ensure effective corrective and preventative actions are implemented.
• Monitor risk indicators and provide meaningful insights to leadership.

Quality Assurance and Clinical Governance

• Drive quality improvement initiatives across the organization.
• Conduct clinical audits and monitor compliance with clinical standards and best practices.
• Support the implementation of evidence-based interventions that improve healthcare outcomes.
• Strengthen clinical governance and quality assurance processes.
  
  Fraud, Waste and Abuse (FWA)
• Develop and implement fraud, waste and abuse detection, prevention and investigation strategies.
• Lead investigations involving providers, members, employees, vendors and other stakeholders.
• Analyse healthcare and claims data to identify suspicious trends and emerging risks.
• Collaborate with internal and external stakeholders to resolve complex cases and recover losses where applicable.
• Monitor the effectiveness of fraud prevention controls and recommend enhancements.
  
  Reporting and Risk Intelligence
• Analyse data and trends to identify opportunities for improvement.
• Develop reports, dashboards and management insights.
• Present findings and recommendations to leadership and governance structures.
• Monitor implementation of corrective actions and measure effectiveness.
  
  Stakeholder Engagement
• Partner with clinical, operational, provider network, compliance and leadership teams.
• Promote a culture of accountability, patient safety, ethical conduct and risk awareness.
• Develop and deliver education and awareness initiatives relating to clinical risk, quality and FWA.

Qualifications

What You Will Bring

Qualifications

• Degree in Nursing, Clinical Associate, Medicine, Pharmacy, Healthcare Administration, or a related healthcare discipline.
• Postgraduate qualification in Risk Management, Clinical Governance, Quality Management, Healthcare Management, Compliance, Forensic Investigation, or a related field will be advantageous.
• Relevant professional registration where applicable.

Experience

• Minimum 7–10 years' experience within healthcare, managed care, health insurance, hospital services, or clinical operations.
• Proven experience in clinical risk management, patient safety, quality assurance, clinical governance, or healthcare compliance.
• Demonstrated experience leading investigations and implementing risk mitigation interventions.
• Experience in fraud, waste and abuse management, healthcare integrity, compliance, auditing, or forensic investigations will be advantageous.
• Experience presenting findings and recommendations to senior management and governance committees.

Skills and Competencies

We are looking for someone who is:

• Highly analytical with strong investigative and problem-solving skills.
• Action-oriented and focused on execution and delivery.
• Able to operate with urgency and decisiveness in managing risk and compliance matters.
• Practical and solutions-driven, with the ability to translate insights into measurable outcomes.
• Confident engaging with stakeholders across all levels of the organization.
• Resilient, adaptable and comfortable working in a dynamic environment.
• Committed to continuous improvement, ethical conduct and excellence in healthcare delivery.

Additional Information

Why Join Us?

This is an opportunity to play a critical role in improving healthcare quality, protecting patients, strengthening organizational integrity, and driving meaningful change. You will work alongside passionate professionals in an environment that values innovation, accountability, collaboration, and continuous improvement.

If you are ready to make a measurable impact and help shape a safer, higher-quality, and more resilient healthcare organization, we encourage you to apply.