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Job: Health Service / Quality Assurance Manager at Markfema Nigeria Limited

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Markfema Nigeria Limited is a health maintenance organization in Nigeria which started operations in 2005 and is duly accredited by the National Health Insurance Scheme (the regulatory body responsible for the implementation of the Social Health Insurance Scheme in Nigeria).Reporting to: MD / CEO

The Candidate

Shall be ready to work hard and push the limits in ensuring claims vetting and fluent management process.
Shall oversee thevetting of all claims submitted by our Providers to ensure they are error and fraud-free
They will manage claims payment and be involved in the resolution of medical cases requiring special attention.

Key Responsibilities

Examine Healthcare Providers’ Claims using the Tariff agreement to determine authenticity and payment.
Decline fraudulent Healthcare Providers’ Claims and state causative reasons.
Forward approved Claims to Team Lead for review and final approval.
Investigate complicated Claims and escalate to the Team lead, if necessary.
Carry out a physical inspection at the assigned provider’s office using the checklist.
Investigate complicated claims by checking the case folder and speaking to the Enrollee and the doctor.
Update Providers’ dashboard, and implement resolutions.

Minimum Qualifications

Minimum of a Bachelor of Medicine and Bachelor of Surgery (MBBS) with a post-graduate qualifications
10 years of work experience.
Previous relevant work experience in a similar role is highly desired
Excellent Numeracy, Analytical and Problem-solving skills.
Strong ability to make judgments on medical/ surgical cases in relation to benefits listed on enrollee’s benefits.
Ability to make a professional judgment on coverage and non-coverage of care requests per time, based on the enrollee’s benefits table.
Candidate must have strong computer skills.

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