Summary
Date Posted:Monday, May 08 2023, Base Salary: Not Disclosed

JOB DETAILS:
Job Purpose
The role will be responsible for scanning values, volumes, patterns and trends in the claims department to inform potential fraud investigations. The officer shall analyse all claims coming from accredited Healthcare Providers to identify suspected health insurance misuse and abuse related to National Health Insurance Scheme (NHIS) members, collecting necessary data as required, and formulating evidence to support the evaluation of suspected cases.
The role shall aid clinical audits, investigations and on-site facility inspections of all accredited Healthcare Providers (HCPs) under the scheme by providing timely information aimed at ensuring compliance with NHIMA requirements, National standard treatment protocols, and other relevant regulatory and contractual obligations. The position will report to the Manager-Facility Inspections.

Key Responsibilities
The key functions of the role will include but not limited to;
A. Stakeholder and Facilities Outcomes
1. Initiate, assess and recommend health facilities for assessment based on claims information
2. Accompany Clinical Audit and Inspections team on on-site investigative and audit visits
3. Ensure compliance to a variety of clinical protocol standards at all accredited Healthcare Providers (HCPs),
4. Keep accurate and detailed records of all information that informed inspections and audits,
5. Participate in stakeholder engagement activities aimed at enhancing quality of insured health services provided,
6. Study NHIS member feedback through customer satisfaction surveys and complaints committees to institute appropriate investigations in ailing accredited health facilities,
7. Liaise with the Complaints Unit and other relevant Authority Units to receive, compile and analyse complaints to inform investigations
8. Participate in the management and implementation of the process of retrospective clinical inspections and clinical audits, including billing practices of high-risk accredited providers and produce appropriate reports,
9. Participate in the development of an annual audit programme which reflects the Authority’s priorities, and is delivered in line with agreed audit procedures,
10. Write clear, concise and comprehensive risk reports and propose recommendations to mitigate or eliminate the identified risks
11. Provide analytical support and guidance to fraud investigation activities,
12. Participate in clinical fraud investigation activities,
13. Provide analytical support and guidance to health risk analysis activity,
14. Identify common areas of non-compliance and provide recommendations for process improvement within NHIMA and accredited healthcare providers

B. Finance and Solvency Outcome
1. Participate in processes to recover overcharging and billing errors identified after inspection of facilities,
2. Participate in processes to monitor utilisation of Claims Advance Payments (CAP) to accredited facilities,
3. Participate in auditing of utilisation of medical equipment in line with Medical Equipment Policy of NHIMA,
4. Participate in the development of departmental revenue and expenditure estimates; and
5. Participate in ensuring inspection activities are within set cost parameters.

C. Staff, Capacity Building and Learning Environment Outcomes
1. Participate in all Unit and departmental trainings and continuous professional development to build dynamic capacity to conduct risk assessments, data analysis, clinical audits and fraud investigations to assigned HCPs in line with the Authority policies.

D. Systems and Control Outcomes
1. Design customised data collection, data analysis and data monitoring tools for claims submitted by all accredited HCPs,
2. Horizon-scan values, volumes, patterns and trends in all claims from all HCPs to inform potential investigations,
3. Horizon-scan types and gravity of complaints in the Complaints Unit to inform the choice of HCPs to investigate in order to improve patient experience,
4. Update and maintain HCP Risk Database in order to record Authority risk exposure, facilitate reporting, and inform audit programme
5. Profile accredited providers, use statistical analysis of provider behaviour, and commission and conduct specific data analysis as required by clinical investigation and audit plan,
6. Provide timely reports to the Manager-Facility Inspections

Knowledge, Skills, Qualifications and Experience
1. Grade twelve (12) School Certificate with at least 5 credits which should include English Language and Mathematics
2. Degree in Actuarial Science, Mathematics, Statistics or equivalent qualifications.
3. Demonstrated proficiency in Microsoft Excel and Power BI
4. Experience in high-volume health insurance claims handling and processing
5. Experience in claims audit and investigations
Minimumof 2 years of experience in a similar role.

Competencies required for this Role
1. Must be willing to travel extensively
2. High level of professional integrity
3. Able to write comprehensive and analytical reports
4. Must be an effective communicator with a good command of the English Language
5. Must possess effective investigative skills
6. Strong attention to detail
7. Must have knowledge and ability to operate basic office equipment such as printers, scanners
8. Must have good interpersonal skills and organisational skills, and
9. Must have excellent time management skills and ability to prioritize work and tasks


Work Hours: 8

Experience in Months: 12

Level of Education: Bachelor Degree

Job application procedure
To apply for this job please visit careers.nhima.co.zm.


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