Quality Assurance Officer at Sigma Consult

Job Summary

• The ideal candidate must be a Professional Doctor, who would work with our Provider Relations Team, Customer Success Teams, Claims and Underwriting teams and make sure that excellent and high-quality service is provided to clients across all provider networks while ensuring resolution of complicated claims and limiting fraud.
• He /She will have major responsibility for managing the relationship between the company, our providers, and our enrollees.
• The ideal candidate would be demanded to track waste, fraud, and/or error from initial point of access to care by enrollees to final claims filing by the Provider.

Responsibilities

• Work with the Provider Team to ensure the minimum standards for quality are met before sign up.
• Inspect and evaluate hospitals to ensure compliance with basic standards.
• Carry out physical inspection at the assigned providers office using the checklist.
• Investigate complicated claims by checking the case folder and speaking to the Enrollee and the doctor.
• Escalate fraudulent cases to the Committee of Doctors.
• Update Providers dashboard, and implement resolutions.
• Recommend changes to improve the efficiencies in the systems and process of the Provider Relations as well as the Claims team.
• Recognize and fix areas of weakness in the system to limit potential for fraud
• Carry out regular hospital quality checks.
• Develop and implement survey tools for patient feedback and communicating data results to Providers to ensure continuous improvement.
• Visit patients in the hospital to ensure they are getting medically necessary care, quality care and that the care is being delivered as efficiently and economically as possible.
• Anticipates the patient's future health care needs and tries to put in place mechanisms to meet those needs as efficiently as possible
• Ensure efficiency and cost-effectiveness of medical services provided to clients
• Takes initiative to present ideas and suggestions to leadership
• Maintains knowledge and proficiency in medical practices through continuing education, staff meetings, and workshops.
• Perform all other duties as assigned.

Requirements

• Minimum 2-year experience in Clinical Practice or Quality assurance role
• Must be a Male Medical Doctor
• Strong ability to make judgment on medical/ surgical cases in relation to benefits listed on enrollee plan.
• Ability to make a professional judgment on coverage and non-coverage of care requests per time, based on the enrollee benefits table.
• Exceptional problem solving and analytical skills
• Excellent communication and presentation skills
• Knowledge of, and sensitivity to, cultural and language differences.
• A demonstration of curiosity, love for learning, execution and speed.

Skills:

• Confidence.
• Excellent technical skills.
• Good numerical skills and an understanding of statistics.
• Leadership skills.
• Planning and organization skills.
• Communication and interpersonal skills.
• Problem-solving skills.
• Teamworking skills.