Head of Medical Operations- MBBS at HRLeverage Africa

Ensure that the unit meets its operational objectives as it relates to providers satisfaction, prompt payment of claims and medical utilization management

Supervise the Unit Lead, Claims and Unit Lead, Provider/Case Management

Responsible and accountable to Management through the Head of Medical Operations.

SPECIFICS

• 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

QUALIFICATION 

• 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 (7) 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

COMPETENCE

• Complex problem solving

• Critical thinking

• Judgment and decision making

• People management

• Collaboration