HMO Medical and Quality Assurance Nurse at Stresert Services Limited

Reference Number QAN-ABJ-25

Job Summary

Our client is an HMO with offices across the six geopolitical zones in the country.

Duties and Responsibilities

• Attend to and resolve all enrollees’ enquiries and ensure that all complaints are promptly resolved on first call resolution, or immediately escalated to the appropriate group or unit.
• Meticulously log all for management analysis and documentation for all relevant stakeholders.
• Follow-up on specific cases as assigned by the line manager for measurable outcomes and stakeholders’ satisfaction.
• Actively and proactively engage in the vetting of bills from the organization’s network of facilities providing secondary/tertiary healthcare services on the public sector social health insurance program
• Benchmark all received claims with the pre-authorized codes given by call center as any service provided by any facility without pre-authorized code is considered null and void.
• Review all the received bills and possibly contact the enrollees for authorization of services provided.
• Investigate and report any incident of abuse, neglect or maltreatment of enrollees immediately to the Management for appropriate actions to be taken.
• Follow up on enrollees on admission in order to evaluate and document their progress and possibly assist the care team with developing and accessing health interventions.
• Participate in case management through scheduled and unscheduled visitation to enrollees on admission.

Education:

• Graduate Professional Nurse and First Degree from an accredited Baccalaureate Nursing Program (University)
• Must be a registered and licensed practitioner.
• Possession of recognized additional training in primary health care and midwifery is desirable.

Experience:

• Applicants must have minimum of 2 years’ experience as a Nurse and Midwifery Professional.
• Ability to work seamlessly with Computer and other communication equipment and software.