Health Insurance Contract and Claims Officer

Job Description

Job Purpose:

The Health Insurance Contract and Claims Officer is responsible for managing and administering contracts and claims related to HMO (Health Maintenance Organization) and international health insurance schemes. This role requires a strong understanding of healthcare contracts, claims processing procedures, and regulatory requirements, particularly those concerning HMOs and international insurance providers. The officer will act as a key liaison between the organization, HMOs, international insurers, and patients, ensuring smooth and efficient processing of claims and adherence to contractual obligations.

Core Responsibilities:

HMO Contract Management:

• Negotiate and manage contracts with HMOs, ensuring favorable terms and conditions for the organization.
• Analyze HMO contracts to identify potential risks and opportunities.
• Monitor HMO performance and compliance with contractual obligations.
• Develop and maintain strong relationships with HMO representatives

International Health Insurance Contract Management:

• Evaluate and select international health insurance providers based on organizational needs and patient demographics.
• Negotiate contracts with international insurers, ensuring comprehensive coverage and competitive pricing.
• Stay abreast of international healthcare regulations and insurance practices.

Claims Processing and Management:

• Oversee the processing of HMO and international health insurance claims, ensuring accuracy, timeliness, and compliance with relevant procedures.
• Investigate and resolve claim discrepancies and disputes.
• Monitor claim trends and identify areas for improvement in claims processing efficiency.

Relationship Management:

• Build and maintain strong relationships with HMOs, international insurers, patients, and internal stakeholders.
• Provide exceptional customer service to patients and address their inquiries regarding claims and coverage.

Compliance and Reporting:

• Ensure compliance with all applicable healthcare regulations, insurance laws, and organizational policies.
• Generate and analyze reports on HMO and international health insurance claims, identifying key performance indicators and trends.

Cost Containment:

• Implement strategies to manage and reduce healthcare costs related to HMO and international insurance claims.
• Negotiate favorable rates with providers and insurers.
• Educate patients on cost-effective healthcare options.

Qualifications

Educational Requirements

• Bachelor’s degree in Insurance, Risk Management, Finance, or a related field.
• Master’s degree in Insurance, Risk Management, or a related field is an added advantage.

Professional Requirements

• Relevant certification (such as PMP, ACA & ACCA) is an added advantage.

Experience Requirements

• 1 - 4 years of experience in insurance administration, claims management, or risk management.
• Experience in the healthcare sector is preferred.

Competeny Requirements

Knowledge Requirements:

• In-depth knowledge of insurance principles, contracts, and regulations.
• Understanding of risk management frameworks and methodologies.
• Knowledge of healthcare industry trends and regulations.
• Familiarity with relevant legal and regulatory requirements.
• Understanding of financial accounting principles.

Skills Requirements:

• Proficiency in using relevant software applications (e.g., spreadsheets, databases, claims management software.
• Understanding of risk management methodologies and techniques.
• Knowledge of insurance principles, contracts, and regulations.
• Proficiency in data analysis and reporting
• Strong analytical and problem-solving skills

Personal Abilities:

• Professional attitude toward work
• Shares the AMCE’s vision.
• Proactive and organized.
• Has personal and professional credibility and commands the respect of colleagues and peers. 
• Supportive and approachable.
• Ability to adapt accordingly.
• High levels of honesty and integrity

Additional Information

African Medical Centre of Excellence, Abuja (AMCE Abuja) aims to be an Employer of Choice, providing equal opportunity for everyone regardless of their background, gender, race and other protected characteristics.