HMO Nurse at Greenbay Healthcare Services Limited

Objective of the Role

• Oversee Identify, accredit, contract, train, and manage the primary care providers and medical specialists who provides services to the enrollees (members) on the company’s health insurance plans.
• Develop, coordinate, implement, and evaluate case management services to health plan enrollees/members and health care providers that contract with the HMO.
• Collaborate with other staff in evaluating placement of members in proper primary care locations, develop and adapt forms and information systems, and mediate difficult member and provider situations.
• Oversight of timely medical management, utilization management, and discharge management interventions to meet clinical targets, assure the provision of a continuum of care to enrollees.

Responsibilities

• Maintaining and supporting the primary care provider and specialist network to the health plans by developing and managing training materials, leading small and large group, on-site initial training sessions on the policies and procedures of the health plan, problem-solving sessions on managing members in the health plan, writing memorandums, letters, or health plan newsletter articles regarding clarification of covered benefits or procedure changes, researching, evaluating, and responding to individual health care provider requests for exceptions to covered services or pharmaceutical benefits, and resolving urgent or complicated individual situations raised by providers.
• Oversee, support, and assist the case management and other Provider Services staff by developing and updating resource materials and comparison grids for easy reference specific to each of the health plans. Delegate and assign job duties, lead biweekly case management meetings to review complicated cases, discuss and revise case management procedures, and inform case management staff of policy changes, provide educational opportunities, and analyze and determine outcomes for difficult member and/or provider situations.
• Assist in the development and implementation of a quality assurance and utilization review program. Develop new policies and procedures and enforces existing standards. Construct, evaluate, and revise forms in consultation with the Medical Services Director.
• Oversee administration of the plan benefits and delivery of care by the Providers. Supervise determination of covered benefits for members and develop procedure lists for complex or detailed tasks related to case management.
• Collaborate with the Medical Services Director in developing, maintaining, and updating a drug formulary and disease Management protocols for the Health Plans. Develop and implement case management plans and policies for Providers. Provide direct case management services by reviewing requests and authorizing specialty service or exceptions to the drug formulary and/or Protocols.
• Identify target populations and health related issues by collecting and analyzing utilization data. Research standards of care and evidence based medicine. Analyze high cost member reports and collaborate with the information systems analyst to develop and reassess a data information system to track medically complicated and high cost medical interventions.
• Evaluate and compile complaints from providers, members, or other Health Plan Management Team members to determine a pattern of complaints and initiate a resolution. Initiate further training sessions, better or more frequent phone or written communications, or reassess current policies in order to control problems.
• Ensure that client records are kept secure and confidential and maintained consistent with Health Department policies and procedures.
• Perform other duties as assigned.

Requirements

• A fully qualified Nurse with minimum 2 – 3 years clinical experience.
• A minimum of 3-5 years’ experience inclusive of clinical experience, in HMO variety of health care settings is required.
• Must be a Registered Nurse in Nigeria with valid certification.
• Proven experience organizing and directing ateam.
• Excellent & persuasive communicator – written and oral.
• Extremely versatile, dedicated to efficient productivity.
• Experience in planning and leading the implementation of strategic initiatives.
• Discretion, display of good judgment.