Head, Claims (Doctor)

Key Responsibilities

· Provide strategic and clinical leadership for the claims function, ensuring efficient, accurate, and timely processing of medical claims.

· Oversee end-to-end claims management, including adjudication, approvals, denials, escalations, and reimbursements.

· Ensure all claims activities comply with clinical standards, organizational policies, regulatory requirements, and contractual agreements.

· Review complex, high-value, and escalated medical claims, providing clinical guidance and final decisions where required.

· Develop and implement claims policies, procedures, and clinical guidelines to improve accuracy, turnaround time, and cost control.

· Collaborate with Provider Management, Medical Services, Finance, and IT teams to ensure seamless claims operations.

· Monitor claims trends, utilization patterns, fraud, waste, and abuse risks, and recommend corrective actions.

· Lead claims audits and support internal and external regulatory reviews.

· Prepare and present claims performance reports, insights, and recommendations to executive management.

· Lead, mentor, and performance-manage the claims team, ensuring continuous capability development and high service standards.

· Provide strategic and clinical leadership for the claims function, ensuring efficient, accurate, and timely processing of medical claims.

· Oversee end-to-end claims management, including adjudication, approvals, denials, escalations, and reimbursements.

· Ensure all claims activities comply with clinical standards, organizational policies, regulatory requirements, and contractual agreements.

· Review complex, high-value, and escalated medical claims, providing clinical guidance and final decisions where required.

· Develop and implement claims policies, procedures, and clinical guidelines to improve accuracy, turnaround time, and cost control.

· Collaborate with Provider Management, Medical Services, Finance, and IT teams to ensure seamless claims operations.

· Monitor claims trends, utilization patterns, fraud, waste, and abuse risks, and recommend corrective actions.

· Lead claims audits and support internal and external regulatory reviews.

· Prepare and present claims performance reports, insights, and recommendations to executive management.

· Lead, mentor, and performance-manage the claims team, ensuring continuous capability development and high service standards.

Qualifications
Bachelor of Medicine, Bachelor of Surgery (MBBS / MBChB or equivalent).
Full registration and valid practicing license with the Medical and Dental Council of Nigeria (MDCN).
Postgraduate qualification in Public Health, Health Management, Health Economics, or a related field is an added advantage.
Minimum of 8–12 years’ post-qualification experience, with at least 4–5 years in a senior clinical, claims, or utilization management leadership role.
Strong experience within an HMO, health insurance, hospital administration, or managed care environment.

Competencies
Strong clinical judgment and decision-making capability.
In-depth understanding of medical claims management, utilization review, and provider billing practices.
Excellent analytical and cost-management skills.
Strong leadership, people management, and team development skills.