Head, Medical and Claims at LEAD Enterprise Support Company Limited

JOB DESCRIPTION  

General Information:

UNIT:                                                     Operations

DIRECTLY REPORTS TO:                    MD

ORGANIZATION:                                   HMO

Job Summary:

Manages day to day claims operations including claim evaluation, adjudication and customer service in accordance with agreed quality and production standards. Processes claims in a timely manner and complies with industry fair claims practices and applicable state regulations concerning the processing of claims. Prepares budget and sets goals, while being accountable for the results.

Manages staff of claims professionals, which may include care coordination and intake nurses, claims examiners, benefit/customer service specialists and administrative support personnel, including the regular and timely evaluation of their performance.

Maintains good, professional working relationship with superiors, peers, subordinates and other department managers and personnel.

Job Functions:

• Design and implement various policies and procedures for claims.
• Provide services to all business requirements and ensure optimal handling of all claims and investigate all issues and provide training for all business units.
• Evaluate all new claims and administer all data integrity data and manage communication to safety department and monitor all claims and ensure timely closure.
• Evaluate all business units’ associate claims.
• Provide training to juniors to manage all outstanding claims and design an efficient duty program and coordinate with HR team to facilitate same.
• Perform regular quarterly audits on all local TPA offices.
• Monitor effectiveness of all programs and provide support to all open claim file reviews and manage all payment cycle to ensure compliance to all contract requirements.
• Design and maintain panel of investigators to use all TPA and prepare reports for monthly chargeback for all business units.
• Analyze all claims to ensure optimal quality and prepare reports for various business units and monitor all chargeback expenses and provide report to all clients and management.
• Perform investigation on all reserve increases and perform regular surveillance of all claim issues and maintain efficient location code listing for TPAs.
• Schedule all internal and external audits on all claims issues and supervise processing of all billing issues.
• Oversee all electronic claims processes and evaluate all self-insurance applications and prepare claims reports and evaluate all actuarial.
• Analyze all claims and identify all risks and ensure processing of all claims as per company policy.
• Forecast all staffing requirements and identify and resolve all issues effectively.

Performance Indicator:

• Clean Claim Rates
•  % of Claims Denied
• How fast are you being paid?
• Percent of AR Greater than 60 days
• Average Days in Accounts Receivable
• Billed amount vs. value at time of charge capture
• Gap between date-of-service and date billed
• Percentage of claims denied due to front-end edits vs. due to coding oversights.
• Percentage of claims denied due to authorization/referral, insurance information or eligibility oversight

Minimum Educational Qualification:

• MSc in Medical field.

Professional Qualification (if any):

• HSE certified or any other health related field is applicable.

Work Experience:

• Minimum of 5 years’ experience in HMO and/or health related organization.

Required Competencies (Knowledge, Skills & Abilities):

• Knowledge of the Healthcare and HMO business
• Customer service skills
• In-depth understanding of client management
• Relationship Management
• Interpersonal skill
• Conflict Management
• Advocacy Skills

Relationships:

• Head Office-Lagos
• Operations Unit
• Accounts unit
• Medical unit
• Enrolment unit
• IT unit
• Call centre
• Internal control/Admin unit