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