HMO Claims Officer at Clinix Healthcare Nigeria

• Clinix Healthcare is seeking a diligent and detail-oriented HMO Claims Officer to join our Health Maintenance Organization (HMO) operations team. We are dedicated to delivering efficient, accurate, and patient-centered healthcare services and are looking for a professional passionate about claims processing, provider relations, and ensuring smooth reimbursement workflows.

Responsibilities

• Process, verify, and adjudicate health insurance claims submitted by providers and patients in line with HMO guidelines and policy terms.
• Review medical bills, treatment authorizations, and supporting documents for completeness, accuracy, and medical necessity.
• Coordinate with healthcare providers, hospitals, and diagnostic centers to resolve claim queries, request additional information, and ensure timely submissions.
• Calculate benefits, apply deductibles, co-payments, and exclusions correctly, and prepare payment/remittance advice.
• Maintain accurate records of claims, approvals, rejections, and payments in the organization’s claims management system.
• Investigate and resolve disputed or rejected claims, including escalation where necessary.
• Ensure strict compliance with NHIS regulations, internal policies, and data protection standards.
• Generate periodic claims reports and provide insights to support management decisions and fraud detection. 

Requirements & Skills

• Strong understanding of health insurance claims processing and HMO operations.
• Excellent attention to detail and analytical skills for reviewing complex medical and billing documentation.
• Good knowledge of medical terminology, ICD-10 coding, and NHIS tariff guidelines.
• Proficient in the use of claims management software and Microsoft Office Suite.
• Strong communication and interpersonal skills for liaising with providers and internal teams.
• Ability to multitask, meet deadlines, and work efficiently under pressure.
• High level of integrity, confidentiality, and ethical conduct in handling sensitive patient and financial data. 

Qualifications

• Bachelor’s degree in Health Insurance, Business Administration, Accounting, Nursing, Public Health, or a related field.
• Minimum of 2–3 years of relevant experience in HMO claims processing, health insurance adjudication, or medical billing.
• Certification in Health Insurance or Claims Management (e.g., from CIIN or relevant bodies) is an added advantage.
• Valid professional certification or license where applicable (for clinical background candidates).