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Medical Officer

Posted On 11th Nov 2021
Location Accra Adabraka, Greater Accra, Ghana
Preferred Qualifications First Degree With Relevant Certification In Insurance Or Health/hospital Administration.
Contract Type Permanent
Min. Years of Exp 4 years
Age Range Any
Preferred Gender Any
Interview Date 25th Nov 2021
Start Date 6th Dec 2021
Preferred Skills Sound Knowledge Of Services And Internal Processes With Sufficient Knowledge Of Regulatory Requirements To Enhance Ability To Deliver Expected Results
Description • Charged With Managing The Assignment And Undertaking Of Full Processing Controls For All Received Claims And All Submitted Refund Requests • Be Responsible For Ensuring Appropriate Interaction And Engagement With Service Providers Is Developed And Maintained To Enhance And Enrich Client Experience Leading To Overall Deep Client Satisfaction • Execute Actions And Strategies To Improve And Maintain Strong Relationships With Service Providers. • Ensure Communication Flow With The Client Relationship Unit To Keep Abreast With Service Complaints By Clients And Leverage On Service Provider Relationships To Promptly Resolve Problems. • Conduct Assessment, Establish Accreditation, Negotiate Price Tariffs, Perform Claim Reconciliations And Obtain Approvals For Service Agreements With All Service Providers. • Charged With Overseeing The Prompt Completion Of Claim Processes And Ensure Diligent Evaluation Has Been Conducted On All Claims Submitted • Perform Duties In A Manner That Ensures Fraudulent And Fictitious Claims Are Detected, Declined And Reported Accordingly. • Actively Ensure Accurate Capturing And Processing Of Correct Claims And Refund Requests To Avoid Errors In Payments • Actively Support The Team To Enhance Capacity And Drive Results • Ensure Diligence In Undertaking Duties To Reduce Risk Of Errors Leading To Possible Losses (operational, Etc.) • Ensure Operational Activities Are Compliant With Internal Policies And To Enable Client Relations Teams Deliver Efficient Services Procedures As Well As Regulatory Requirements. • Ensure Timely Completion Of Processes To Clients • Ensure The Protection Of Confidential Information Concerning Patients Obtained In The Course Of Professional Practice And Make Disclosures Only With The Patient Consent Or When Disclosure Can Be Appropriately Justified • Provide Leadership For The Medical And Nursing Team At The Clinic • Ensure The Organization And Management Of Medical And Nursing Care At The Clinic Ensuring That Patients Are Treated With Respect And Dignity At All Times • Ensure Maintenance Of A Safe And Therapeutic Environment For Patient Care Within The Clinic • Conduct Final Vetting And Approval For All Claims (consider Diagnoses, Check For Appropriateness And Correctness, Bio Data, Policy Exclusions, Etc). • Ensure The Inspection And Accreditation Of All Service Providers And Ensure It Is Conducted In Accordance With NHIA Regulations And Credentials. • Engage In The Training Of Service Providers In Claims Processing/submission And Claims Software System Usage • Ensure The Installation Of Claims Submission Software For Designated Service Providers Have Been Conducted By Their Designated Provider Relations Officer • Ensure The Pre-authorization Of Special Cases And Services I.e. Specific Drugs, Diagnostics/tests, Etc Including All Surgical Procedures Before They Are Carried Out Or Provided. • Ensure Prompt Escalation Of Requests For Special Services That Exceeds Delegated Authority For Attention And Approval • Approve Or Obtain Approval For All Pro-forma Invoices For Providers To Proceed With Special Service/procedure • Conduct Clinical And Financial Checks On Service Providers • Oversee The Negotiation (or Where Necessary Directly Negotiate) Approve And Where Necessary Obtain Approval From Senior Management For All Tariffs Agreed With Providers • Ensure Appropriate Reviews And Approvals Are Sought From Legal, Compliance And Where Necessary, Risk, And Are In Place For All Contracts That Vary Materially From The Standard Agreement. • Make Prudent Decisions And Judgments Calls Regarding Administrative Or Diagnostic Irregularities Discovered During Claims Processing/review And Ensure Resolution And Regularization • Arrange For Service Provision Abroad In Cases Where Clients Have To Seek Medical Attention Outside Ghana Due To Unavailability Of That Service Or In Cases Where Clients Are Willing To Bear Cost Of Services In Ghana Or Abroad That Exceed The Benefit Limit Of Their Company Care Policy. • Ensure The Conduct Of Mystery Shopping/visits At Service Provider Facilities To Ascertain If Claims Are Actually For Services Rendered To Clients • Ensure Spot Or Sampled Checks Are Performed On Sampled Services Provided Or Claims Submitted By Conducting Call- Backs • Ensure Approved Claims Are Processed For Payment And Cheques Are Collected Or Delivered To Clients And Providers. • Ensure All Claims-related And Provider-related Forms Are Approved And Any Changes Are Put Through Same Procedure • Ensure Provider Evaluations Are Done Periodically To Ensure That Accreditation And Expected Standards Are Valid And In Place After Initial Accreditation Was Conducted. Other Roles Related; • Appreciable Relevant Knowledge Or Experience In Medical/hospital/health Administration • Strong Dexterity And Skill In Determining Errors Or Falsities • Appreciable Experience In The Insurance Industry Or Other Financial Industry An Advantage. • Sound Knowledge Of Internal Processes With Sufficient Knowledge Of Medical, Health And Insurance Regulatory Requirements To Enhance Ability To Deliver Expected Results. • Strong Interpersonal Skills Coupled With Professional Integrity In Order To Command Respect And Credibility With Internal Stakeholders And In Situations Involving Conflicting Interests. • Good Understanding Of Services Relevant To Health Insurance Provision. • Ability To Withstand Pressure, Work Fast, Set Priorities And Organize And Manage Time Among Situations Needing Urgent Attention Simultaneously, With Initiative, Creativity, Resourcefulness, Analytical Ability, Energy And Determination To Successfully Perform Tasks
Conditions None