Program Officer, Claims Management and Payment Processes (Consultancy) at Palladium Group

Location: Abuja (with regular travel to the States)
Reporting: The Secretariat of the National Steering Committee (TS-NSC)

Background

• Nigeria has committed to achieving Universal Health Coverage (UHC) and has put in place the enabling policy1 to achieve this. At the Federal level, there’s the recognition of the role of States as drivers and providers of primary health care service delivery. This is consistent with the ‘Bringing PHC under One Roof’ (PHCUOR) policy that was instituted and ratified by the National Council on Health in 2011. The policy aims to strengthen PHC systems through the creation of State PHC Boards that would allow for integration and/or decentralization of PHC services management.
• Whilst acknowledging the separation of functions and the role of States in the management and organization of performance for PHC service delivery, a National Health Act (NHAct) was enacted into law in 2014. The NHAct specifies that all Nigerians shall be entitled to a Basic Minimum Package of Health Services (BMPHS). With the BMPHS, Nigeria aims to create a minimum “health floor” and provide a defined set of services for all Nigerians in line with its UHC goals.
• To guarantee the BMHPS, the Basic Health Care Provision Fund (BHCPF) was established under Section 11 of the National Health Act, as its principal funding vehicle for the BMPHS.

Job Summary

• The Federal Ministry of Health in; conjunction with NPHCDA & NHIS have developed the operations manual for the roll out of the implementation of BHCPF. To ensure adequate governance for the program, the secretariat has been set up to provide stewardship of fund use and program execution.
• Consistent with the tenets of the NHAct, the funds will be:
  • Used in strengthening service delivery by providing accredited PHCs with operational expenses and;
  • Purchasing the BMPHS for beneficiaries.
• The BHCPF will be implemented in the 18 States + FCT.
• The TS=NSC seeks to hire a suitable candidate to provide the framework for the reimbursements; of services rendered, support State teams with claims verification and processing and broader strategic purchasing approach. Amidst concerns of high financial barriers to accessing care at the PHC level, it is necessary to reduce out of pocket expenses paid at the point of use, reimburse facilities swiftly for services rendered, and maintain a solid IT platform to support the process.

In this role, the candidate will work closely with the relevant agencies at federal and state level:

• Evaluate different provider payment method options for different levels of care, with the ultimate objective of using incentives to improve health care quality and minimize the risk of opportunistic behavior amongst accredited health care providers;
• Develop context specific strategic purchasing approaches that are geared towards allocative efficiencies and incentivize high quality of care;
• Design and develop templates for the claims documentation and submission by healthcare facilities;
• Develop materials documenting processes for case management by the purchaser at the state level, with input from relevant state policymakers (e.g. state-sponsored health insurance leaders, when applicable), with a focus on effective and efficient verification of claims;
• Design and support the States to adopt a coding system for documentation of healthcare services and claims processing;
• Design and develop standard operating procedures for claims submission, management and reimbursement;
• Determine and itemize the linkages between claims form and the District& Health Information System (DHIS) reporting platform, with a view to ensuring alignment;
• Design and develop monitoring and evaluation mechanisms to continually track claims reimbursement operations, identify bottlenecks and present leadership with solutions to address these;
• Develop standard operating procedures for fraud detection and management;
• Through the secretariat, engage with NHIS, NPHCDA, FMOH, State level and other stakeholders to foster collaboration on and adoption of the deliverables listed in this ToR;
• Train and support State teams in claims verification, recording and payment;
• Support in the development and documentation of a provider payment system - method of reimbursing providers for services rendered, classification of product, counting of reimbursed services, tariff setting (pricing), and reporting.

Other functions will include but not limited to:

• Represent the organization at the highest levels in specific technical areas and provide leadership in the fields of strategic purchasing, claims processing and payment systems;
• Liaise with technical and programmatic leaders from various federal, parastatal and state level institutions as necessary in order to perform the above tasks;
• Continually identify and implement opportunities for TMSOF to add value and maximize impact through well-designed provider payment mechanisms;
• Ensure proper execution of required initiatives to strengthening the claims management systems
• Assist other units in related elements of their work
• Perform any other tasks as designated.

Requirements
Qualifications and Experience:

• Minimum of a Master's level qualification from an internationally recognized University in Health Economics or Economics or Financial Management / Accounting
• Minimum of seven years’ experience working in a related function in a Health Management Organization preferably in a Nigerian context.
• Significant proven practical experience of claims data processing and design of payment mechanisms. Ideally candidates will have played a role in reviewing a national program.
• Minimum of 7 years of experience in designing, administering, implementing or monitoring a national or subnational (state) level provider payment system
• Experience of results’ delivery of programmes.
• Proven cultural, social and political sensitivity of working in Nigeria at different levels of government.

Technical Competencies:

• This role requires a combination of technical and management skills. Primary competencies include:
  • Proficiency in using Microsoft packages
  • Demonstrated ability to conduct quantitative analysis
  • Ability to build and foster collaborative relationships with relevant partners to inform programmes and policy
  • Make effective decisions using complex data, policy documents and similar information on health financing issues
  • Ability to demonstrate a degree of specialist knowledge and results in three following core areas:
    • Health Insurance
    • Clinical Care Management
    • Advocacy

Behavioral Competencies:

• Capture: Ability to assess and interpret information to use it to inform non-technical colleagues
• Deliver at pace: Ensure tasks are done to the required standard and deadlines; plan work to meet individual, team and office wide objectives.
• Lead and communicate: Communicate clearly both orally and in writing, using appropriate language; communicate on a range of issues to diverse internal and external audiences.
• Collaborate and partner: Excellent team player; ability to work effectively with government, development partners, civil society and private sector stakeholders, including traditional and religious leaders; ability to build good relationships for partnership, implementation, and support for the working group’s programmes.
• Contextualize: Ability to develop an in-depth understanding and knowledge of how the role fits and supports organizational objectives and wider public needs.