Posted on: Wed 06-07-2022

Lead Enterprise Support Company Limited is a foremost Human Resources Solutions organization with many years of cumulative experience and expertise. We are prolific in Outsourcing, Recruitment, Head hunting and HR Advisory. We are a multi-sectorial servicing company, with landmark service deliverables to our clients in varied industries.

We are recruiting to fill the position below:

Job Title: Head, Medical and Claims

Location: Lagos

Employment Type: Full-time

Unit: Operations

Directly Reports To: MD

Organization: HMO

Job Summary

• Manages day to day claims operations including claim evaluation, adjudication and customer service in accordance with agreed quality and production standards. Processes claims in a timely manner and complies with industry fair claims practices and applicable state regulations concerning the processing of claims. Prepares budget and sets goals, while being accountable for the results.
• Manages staff of claims professionals, which may include care coordination and intake nurses, claims examiners, benefit/customer service specialists and administrative support personnel, including the regular and timely evaluation of their performance.
• Maintains good, professional working relationship with superiors, peers, subordinates and other department managers and personnel.

Job Functions

• Design and implement various policies and procedures for claims.
• Provide services to all business requirements and ensure optimal handling of all claims and investigate all issues and provide training for all business units.
• Evaluate all new claims and administer all data integrity data and manage communication to safety department and monitor all claims and ensure timely closure.
• Evaluate all business units’ associate claims.
• Provide training to juniors to manage all outstanding claims and design an efficient duty program and coordinate with HR team to facilitate same.
• Perform regular quarterly audits on all local TPA offices.
• Monitor effectiveness of all programs and provide support to all open claim file reviews and manage all payment cycle to ensure compliance to all contract requirements.
• Design and maintain panel of investigators to use all TPA and prepare reports for monthly chargeback for all business units.
• Analyze all claims to ensure optimal quality and prepare reports for various business units and monitor all chargeback expenses and provide report to all clients and management.
• Perform investigation on all reserve increases and perform regular surveillance of all claim issues and maintain efficient location code listing for TPAs.
• Schedule all internal and external audits on all claims issues and supervise processing of all billing issues.
• Oversee all electronic claims processes and evaluate all self-insurance applications and prepare claims reports and evaluate all actuarial.
• Analyze all claims and identify all risks and ensure processing of all claims as per company policy.
• Forecast all staffing requirements and identify and resolve all issues effectively.

Performance Indicator

• Clean Claim Rates
• % of Claims Denied
• How fast are you being paid?
• Percent of AR Greater than 60 days
• Average Days in Accounts Receivable
• Billed amount vs. value at time of charge capture
• Gap between date-of-service and date billed
• Percentage of claims denied due to front-end edits vs. due to coding oversights.
• Percentage of claims denied due to authorization/referral, insurance information or eligibility oversight

Minimum Educational Qualification

MSc in a Medical field.

Professional Qualification (if any):

HSE certified or any other health related field is applicable.

Work Experience:

Minimum of 5 years’ experience in HMO and/or health related organization.

Required Competencies (Knowledge, Skills & Abilities):

• Knowledge of the Healthcare and HMO business
• Customer service skills
• In-depth understanding of client management
• Relationship Management
• Interpersonal skill
• Conflict Management
• Advocacy Skills

Relationships:

• Head Office-Lagos
• Operations Unit
• Accounts unit
• Medical unit
• Enrolment unit
• IT unit
• Call centre
• Internal control/Admin unit.

Application Closing Date

15th July, 2022.

Method of Application

Interested and qualified candidates should send their CV to: [email protected] using the Job Title as the subject of the email.

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