Claims Data & Reimbursement

Key Responsibilities and Accountabilities
▪ Sign up providers across the region.
▪ Provider selection and management: enlisting, negotiating, delisting, rewarding, training, and enlightenment of providers on the network.
▪ Working with other provider network managers in the region to develop the provider network
▪ Tariff negotiation and review
▪ Contract and SLA management
▪ Scheduling major and highly specialized patient procedure
▪ Referral and monitoring of complex cases
▪ Utilization Review Management
▪ Encounter data analysis
▪ Providers audit and quality assurance: this involves infrastructure audit, compliance and service quality
▪ Review of care delivery protocols
▪ Analysis of hospitals tiers and capability
▪ Quality assurance reports on providers to ensure compliance without compromising quality
▪ Provider complaint escalation and resolution.
▪ Cost control and cost containment.
▪ Ensuring healthy and mutually beneficial relationships between Bastion Health and providers
▪ Coordination of emergency cases

Key Performance Indicators

• Hospital spread – Lagos and southwest
• Provider satisfaction index
• Customer satisfaction index
• Average encounter per member per provider
• Average length of stay in the hospital
• Average cost per encounter
• Claims ratio

Job Requirements
• BSN from a certified University/ RN from a certified Nursing College
• 2 years of experience being a Medical Doctor.
• HMO experience will be an added advantage.
• Explicit understanding of Medical Cases and Terminologies