Unit Lead, Medical Operations at HRLeverage Africa

Job Description

• 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

Responsibilities

• 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 B.Sc Degree in 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