To lead the hospital's managed-care function, owning the interface with HMOs and retainership schemes, and ensuring enrolee service, claims and authorization 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-authorization, referrals, and management of care within scheme terms.
- Oversee claims preparation, submission, reconciliation, and follow-up to minimize 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 processes.
- Understanding of claims, authorization, and revenue-cycle management.
- Ability to align clinical and commercial requirements.
- Ability to lead, coach, and develop a team.Strong communication, negotiation, and analytical skills.
- Working 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, authorizations and HMO/scheme relationships.
- Experience supervising staff and managing service performance.
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.