Jobs at MetroHealth HMO Limited

Job Description

• Review daily in-process report for new assigned claims
• Request documentation from Office Assistant needed to complete clinical review of assigned claims
• Review coding of professional bills utilizing requested procedural notes
• Review itemized bill and medical records for medical appropriateness and inconsistencies by performing a line by line clinical review of claim
• Research unfamiliar procedures as needed via web
• Contact provider's representative to resolve billing issues
• Contact provider's representative to negotiate claim
• Confirm repricing information with provider
• Provide status of outstanding claims upon request
• Prepare management reports of findings for submission to clients

Requirements

• The ideal candidate must be a Registered Nurse
• Should posses minium of 2 years experience (HMO experience will be an added advantage).

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Job Description

• Responsible for the crafting and directing the strategic direction of the company to ensure that members have access to quality healthcare in a conducive provider environment at a reasonable cost that guarantees operational profitability
• Oversees Care coordination, Case management, Provider Administration, Call Centre and Quality Assurance units in the company
• Formulate policies and initiatives for effective provider network management, medical cost management, quality assurance and cordial relationship with providers that results in excellent service delivery
• Assist with product development, working in conjunction with Heads of underwriting and business development to periodically review plan benefits in line with historical utilization patterns to and the competition to mitigate risks and ensure operational profitability
• Ensure medical cost control through analyses and trending of utilization patterns and formulate and execute measures to minimize medical cost.
• Develop relationships with the leaders of healthcare providers to ensure service excellence and no disruption of service by healthcare providers.

Requirements

• First Degree in Medicine from a recognized Institution.
• Experience: 3 years and above with the HMO space.

Job Skills:

• Critical thinking
• Problem solving skills
• Time Management and Excellent communication skills
• Teamwork skills
• Knowledge of Health Insurance will be an advantage
• Excellent written and verbal communication skills.