• Nigeria


  • Permanent

  • Full-time

MetroHealth HMO is a Nigerian leading health management organization with an aim to render unparalleled technology-based and comprehensive primary, secondary, and tertiary health care services across the country. MetroHealth was registered by the regulatory authority, the National Health Insurance Scheme (NHIS) to operate as a national HMO in 2013.

With over 650 partner hospitals, we are committed to rendering world-class preventive and curative health care services to our clients in the easiest and stress-free method. We understand that every client is unique and deserves flexible, specialized solutions; therefore we embrace an individualized approach towards taking excellent care of our clients.

We are big on maximizing the blessings of technology to render 21st century-based health services making sure our clients are in the best state of health.

We are recruiting to fill the position below:

Job Title: Care Coordinator

Location: Lagos Island, Lagos

Employment Type: Full-time

Report To: Head, Medical Service

Department: Medical Service

Job Responsibilities

  • Educate providers on new systems, processes and procedures in managed care and health insurance.
  • Provider engagements via visits and phone calls for necessary updates and follow up
  • Coordinate, track and monitor the administration of exclusions and to ensure prompt payments by all parties and payment to the providers.
  • Development and implementation of patient care policies and protocols
  • Case management reports
  • Credentialing review
  • Credentialing report
  • Provider contracting report.
  • Organizational process mapping
  • Administrative process review (filing system audit, system fee schedule audits, system benefit and premium audit)
  • Client and provider contract reviews
  • Provider satisfaction survey report
  • Managing the implementation of the Medicloud technology platform as it relates to providers, and contributing to the website content and implementation with Medical and non-medical interventions.
  • Provider Relations
  • Performance Indicators: Turnaround time for issuing, Pre-authorization., Reduce denial of care to enrollees, Low Medical cost
  • Provider enlightenment activity report
  • Medical records review
  • Notify providers of changes in HMO operational modalities.
  • Monitor and coordinate care of the enrollees and ensure care coordination within and outside of network
  • Prepare and provide case note audits, report and recommend improvement
  • Carry out onsite investigation of complaints with a view to resolving them.
  • Investigate critical incident and reviewing outcome of results
  • Handle grievance and complaints from all stakeholders – enrollees, clients and providers
  • Coordinate emergency out of network care and enrollee referrals.
  • Provider satisfaction reviews
  • Provider termination & disengagement reviews
  • Provider report carding & incentivizing reports
  • Network adequacy assessment report
  • Provider accessibility and availability report

Marketing:

Work with cross functional teams in order to generate new business. This will involve:

  • Carrying out presentations
  • Participation in Preventive Health programmes and Community Outreach events

Utilization:

  • Comprehensive utilization management and control through preauthorization review and case management analysis.
  • Utilization Management and Evaluation reports
  • Proactive review of pre-authorization/encounter data to determine discrepancies, trends and opportunities for disease management and allied medical and interventions.
  • Ensure improvement in medical cost management with reduction in medical loss ratio
  • Performance Indicators: Enrolee complaint rate, Provider complaint rate, Enrolee & provider successful appeals ratio
  • Case management of all Pre-authorizations, enrollee visits and enrollee call back.
  • Enrolee refund investigation and reviews
  • Provider appeal reviews

Service Quality Improvement:

  • Administrative process review (filing system audit, system fee schedule audits, system benefit and premium audit)
  • Perform all other functions as may be assigned from time to time
  • Performance Indicators: Registration error rate
  • Client and provider contract reviews
  • Maintenance of a dashboard of available skills and equipment within the provider network

Requirements

  • MBBS
  • Minimum of 10 years post NYSC experience in clinical practices
  • Effective time management, communication and organizational skills.
  • Previous experience of working in an HMO.
  • Valid practitioners license
  • Fully qualified and registered with Medical and Dental Council of Nigeria

Skills:

  • Effective communication and Reporting skill.
  • Proficiency in use of Microsoft office applications

How to Apply

Interested and qualified candidates should send their CV to: using the JobTitle as the subject of the mail

Employment Nigeria