To manage the day-to-day interface with assigned HMO and retainership schemes, handling enrolee verification, authorisations, referrals and claims to support smooth enrolee care and timely reimbursement.
- Verify enrolee eligibility and process pre-authorisation and referral requests within scheme terms.
- Prepare, submit, track and reconcile claims, and follow up promptly on rejections and outstanding payments.
- Liaise with assigned scheme partners on authorisations, queries and disputes.
- Coordinate with clinical teams to ensure care is delivered within scheme rules and properly documented.
- Respond to enrolee enquiries and complaints, escalating as needed.
- Maintain accurate managed-care records and produce regular activity reporting.
- Working knowledge of HMO and retainership processes, authorisations and claims.
- High attention to detail and accuracy in claims and records.
- Ability to liaise effectively with scheme partners and clinical teams.
- Effective communication and problem-solving.Competent use of relevant claims/records systems.
Certification relevant to health insurance or managed care.
- Minimum of 4 years of relevant experience in managed care/HMO operations, health insurance or healthcare administration.
- Experience in managed care, health insurance, HMO operations or hospital claims/billing.
- Experience handling authorisations, claims and enrolee queries.
- Experience working with clinical teams to deliver care within scheme rules.
A relevant first degree or HND (e.g. health sciences, nursing, public health, business administration, or a related discipline). Completion of NYSC, or a valid exemption where applicable.