Medical Claims Manager at LEAD Enterprise Support Company Limited

LEAD Enterprise Support Company Limited is a foremost Human Resources Solutions organization with many years of cumulative management 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: Medical Claims Manager

Location: Lagos
Employment Type: Full-time
Organization: HMO
Unit: Operations
Direcly Reports To: MD

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.

Job Grade Level:

• 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.

Specific Duties & Responsibilities

• 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 Indicators

• 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.

Qualifications
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 Health care 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
19th August, 2022.

Method of Application
Interested and qualified candidates should send their CV to: recruitment@leadhradvisory.com using the Job Title as the subject of the email.