Job Summary
The Internal Auditor ensures that all financial, operational, and regulatory processes within the HMO comply with the National Health Insurance Authority (NHIA) Act, internal policies, and industry standards. The role involves conducting routine audits, identifying risks, preventing fraud, improving internal controls, and ensuring that provider claims, enrollee management processes, and financial transactions are accurate, transparent, and compliant.
Key Responsibilities
Financial and Operational Audit
- Conduct periodic audits of all financial transactions, including premiums, capitation, claims, and provider payments.
- Review financial statements and accounting systems for accuracy and compliance with standards.
- Verify revenue inflows, expenditures, reconciliations, and budget performance.
Compliance & Regulatory Monitoring
- Ensure strict compliance with the NHIA Act, 2022, NHIA guidelines, and HMO regulatory obligations.
- Review internal controls and procedures to ensure alignment with statutory requirements.
- Monitor adherence to audit recommendations.
Claims & Medical Operations Audit
- Audit hospital/healthcare provider claims to detect fraud, abuse, and irregularities.
- Review pre-authorizations, case management records, and enrollee utilization patterns.
- Ensure that tariff payments, encounter data, and reimbursement processes are properly documented.
Risk Management
- Identify operational, financial, and compliance risks within the organization.
- Recommend risk mitigation strategies and improvements in control mechanisms.
- Conduct fraud-risk assessments and support investigations where necessary.
Performance Audit
- Audit internal departments (IT, Provider Relations, Call Center, Enrolment, Underwriting, Finance, etc.) for process efficiency.
- Evaluate the adequacy of internal controls and recommend improvements.
Reporting & Documentation
- Prepare audit reports detailing findings, recommendations, and corrective action plans.
- Maintain comprehensive documentation for all audit activities and investigations.
- Present audit outcomes to management and follow up on implementation of recommendations.
Investigation & Special Assignments
- Investigate suspected fraud, unethical behavior, misappropriation, or breaches of policy.
- Conduct spot checks at hospitals, enrollee offices, corporate clients, and field teams.
- Assist management in ad-hoc audits and strategic initiatives.
Requirements
Education
- Bachelor’s degree in accounting, Finance, Economics, Business Administration, or related field.
- Professional qualifications: ICAN, ACCA, CISA, CIA, CRMA (completed or in-progress).
Experience
- Minimum of 8 years audit experience, preferably in:
- HMO/Health Insurance
- Healthcare/Provider Audit
- Financial Services or Insurance
- Strong knowledge of NHIA regulations and HMO operations is an advantage.
Skills & Competencies
- Strong analytical and investigative skills.
- Excellent understanding of internal control frameworks.
- Ability to detect inconsistencies, fraud, and operational weaknesses.
- Proficiency in MS Excel, audit software, and accounting tools.
- Strong reporting, communication, and presentation skills.
- High level of integrity, confidentiality, and professionalism.
- Ability to work independently and manage multiple assignments.
Compensation & Benefits
- Competitive salary.
- Health insurance coverage.
- Professional development opportunities and audit training.
- Transport allowance or field work benefits (where applicable).
- Performance-based bonuses.
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