Our client who is a Health Maintenance Organisation is currently in need of an experienced Medical officer to supervise “Claims and Unit Lead” and “Provider/Case Management”. The ideal candidate will also be responsible and accountable to Management through the Head of Medical Operations.
- Supervise and manage day-to-day itinerary of Case Managers
- Supervise and manage the day-to-day Case Management activities, utilization reviews, quality management activities and medical outreach or education programs
- Collate report of medical case reviews/audit, present findings, propose improvement plans and monitor strict execution of the improvement plans
- Collate report of utilization reviews, present findings, propose solution and monitor implementation of plans
- Collate report of accreditation and re-accreditation of providers and present findings for approval
- Co-ordinate and collate report of claims reconciliation with providers, present findings and resolutions and monitor execution of resolutions as well as collection of Letters of Non-Indebtedness (LONI)
- Co-ordinate the collation of regulatory report including monthly Fee-For-Service FFS) and Referral report, Quarterly Provider Sensitization and Itinerary report
- Co-ordinate the Pharmacy Benefit Program (Pharm-Assist) to manage medical cost from drugs (medications) without compromising client convenience
- Co-ordinate Medical Referral program to manage medical cost without compromising client convenience
- Co-ordinate the Claims Administration team to ensure prompt claims processing and payment to providers in line with the organization’s contract with the providers
- Manage high level relationships within every healthcare facility to ensure continued high quality service delivery
- Coordinate the prompt resolution of all escalated provider or claim grievance issues
- Monitor and evaluate the day-to-day performance of the Case Managers and Claims Adjusters.
- MBBS or BSc Nursing from an accredited College, MPH or MBA would be an added advantage
- Minimum of nine (9) years Post-Qualification experience
- Minimum of seven (3) years cognate experience in a Health Maintenance Organisation (HMO)
- Must have led a team of ten (10) staff minimum
- Proven track record of achievement and high performance with evidence.
Applications can be sent to resume@HRLeverageafrica.com
Only candidates who meet the above requirements will be considered.