MetroHealth HMO is a Nigerian leading health management organization with an aim to render unparalleled technology-based and comprehensive primary, secondary, and tertiary health care services across the country. MetroHealth was registered by the regulatory authority, the National Health Insurance Scheme (NHIS) to operate as a national HMO in 2013.
With over 650 partner hospitals, we are committed to rendering world-class preventive and curative health care services to our clients in the easiest and stress-free method. We understand that every client is unique and deserves flexible, specialized solutions; therefore we embrace an individualized approach towards taking excellent care of our clients.
We are big on maximizing the blessings of technology to render 21st century-based health services making sure our clients are in the best state of health.
We are recruiting to fill the position below:
Job Title: Care Coordinator
Location: Lagos Island, Lagos
Employment Type: Full-time
Report To: Head, Medical Service
Department: Medical Service
Job Responsibilities
- Educate providers on new systems, processes and procedures in managed care and health insurance.
- Provider engagements via visits and phone calls for necessary updates and follow up
- Coordinate, track and monitor the administration of exclusions and to ensure prompt payments by all parties and payment to the providers.
- Notify providers of changes in HMO operational modalities.
- Monitor and coordinate care of the enrollees and ensure care coordination within and outside of network
- Prepare and provide case note audits, report and recommend improvement
- Carry out onsite investigation of complaints with a view to resolving them.
- Investigate critical incident and reviewing outcome of results
- Handle grievance and complaints from all stakeholders – enrollees, clients and providers
- Coordinate emergency out of network care and enrollee referrals.
- Development and implementation of patient care policies and protocols
- Managing the implementation of the Medicloud technology platform as it relates to providers, and contributing to the website content and implementation with Medical and non-medical interventions.
- Provider Relations
- Performance Indicators: Turnaround time for issuing, Pre-authorization., Reduce denial of care to enrollees, Low Medical cost
- Provider enlightenment activity report
- Medical records review
- Provider satisfaction survey report
- Provider satisfaction reviews
- Provider termination & disengagement reviews
- Provider report carding & incentivizing reports
- Network adequacy assessment report
- Provider accessibility and availability report
- Case management reports
- Credentialing review
- Credentialing report
- Provider contracting report.
- Organizational process mapping
- Administrative process review (filing system audit, system fee schedule audits, system benefit and premium audit)
- Client and provider contract reviews
Marketing:
Work with cross functional teams in order to generate new business. This will involve:
- Carrying out presentations
- Participation in Preventive Health programmes and Community Outreach events
Utilization:
- Comprehensive utilization management and control through preauthorization review and case management analysis.
- Utilization Management and Evaluation reports
- Case management of all Pre-authorizations, enrollee visits and enrollee call back.
- Enrolee refund investigation and reviews
- Provider appeal reviews
- Proactive review of pre-authorization/encounter data to determine discrepancies, trends and opportunities for disease management and allied medical and interventions.
- Ensure improvement in medical cost management with reduction in medical loss ratio
- Performance Indicators: Enrolee complaint rate, Provider complaint rate, Enrolee & provider successful appeals ratio
Service Quality Improvement:
- Administrative process review (filing system audit, system fee schedule audits, system benefit and premium audit)
- Client and provider contract reviews
- Maintenance of a dashboard of available skills and equipment within the provider network
- Perform all other functions as may be assigned from time to time
- Performance Indicators: Registration error rate
Requirements
- MBBS
- Minimum of 10 years post NYSC experience in clinical practices
- Valid practitioners license
- Fully qualified and registered with Medical and Dental Council of Nigeria
- Effective time management, communication and organizational skills.
- Previous experience of working in an HMO.
Skills:
- Effective communication and Reporting skill.
- Proficiency in use of Microsoft office applications
How to Apply
Interested and qualified candidates should send their CV to: metrovacancies@gmail.com using the JobTitle as the subject of the mail.
