About the role
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.
Responsibilities
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.
Required skills
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.
Experience
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.
Education
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.