To lead the hospital's managed-care function, owning the interface with HMOs and retainership schemes, and ensuring enrolee service, claims and authorisation processes deliver both quality care and commercial sustainability.
- Direct the hospital's managed-care operations and manage relationships with HMO and retainership partners.
- Oversee enrolee verification, pre-authorisation, referrals and management of care within scheme terms.
- Oversee claims preparation, submission, reconciliation and follow-up to minimise rejections and delays.
- Monitor service-level agreements and lead resolution of disputes with scheme partners.
- Coordinate with clinical teams to ensure care is evidence-based, cost-effective and within scheme rules.
- Supervise, coach and develop managed-care, clinical support and customer experience staff.
- Track managed-care performance and revenue, and report findings with improvement recommendations.
- Champion enrolee experience, complaints resolution and retention across the function.
- Strong knowledge of managed-care, HMO and retainership processesUnderstanding of claims, authorisation and revenue-cycle managementAbility to align clinical and commercial requirementsAbility to lead, coach and develop a team
- Strong communication, negotiation and analytical skillsWorking knowledge of managed-care/claims systems and performance reporting
- Minimum of 8 years of relevant experience in managed care, HMO liaison or healthcare administration, including supervisory experience.
- Substantial experience in managed care, health insurance, HMO operations or hospital revenue-cycle management.
- Experience coordinating claims, authorisations and HMO/scheme relationships.
- Experience supervising staff and managing service performance.
- Role-specific: Experience working at the interface of clinical and commercial functions in a healthcare setting.
A relevant first degree (e.g. health sciences, nursing, public health, business administration, or a related discipline). Completion of NYSC, or a valid exemption where applicable.