HMO Audit / Claims Manager Job at DEDA Hospital

DEDA Hospital is a leading Nigerian healthcare provision facility with a history of successful health outcomes for our clients. Started Operations in 2012, DeDa hospital is home to an array of experienced healthcare providers and administrators from across the world with a dedication to delivering optimal healthcare service, especially to women, children and families. For over 6 years, DeDa hospital has provided Abuja, Nigeria and the International world with high quality, compassionate healthcare.

We are recruiting to fill the position below:

Job Position: HMO Audit / Claims Manager

Job Location: Abuja
Employment Type: Full-time

Job Description


  • Reviewing insurance claims for accuracy, including reviewing medical records for documentation of services rendered and items supplied.
  • Conducting onsite audits of hospitals, clinics, nursing homes, home health agencies, or other facilities to ensure that they are adhering to safety standards and ethical guidelines
  • Assisting patients with filing appeals or grievances with their insurance companies regarding coverage or payment issues. 
  • Making recommendations to improve patient care based on findings of the audit.
  • Reviewing and analysing data to identify possible areas of concern or risk to patients.
  • Conducting internal audits to ensure compliance with federal regulations such as Medicare guidelines.
  • Reviewing clinical documentation to determine whether or not it meets established standards of Managed care business. 
  • Conducting audits of pharmacies to ensure that medications are dispensed properly and accurately.
  • Conducting routine audits of insurance claims to ensure that they have been processed correctly.
  • Review medical records to ensure that documentation meets all requirements for billing and coding.
  • Identify errors in documentation and work with providers to correct them.
  • Develop and implement policies and procedures related to billing.
  • Train new staff members on billing and coding procedures.
  • Participates in all claims audit with HMO and corporate organization to ensure full recovery of all forms.
  • Liaise with Managing team to prepare medical reports for all HMO patient management cases for either OPD or inpatient.
  • Respond to queries and enquiries from HMOs on patient management.
  • Educate providers on proper documentation techniques.
  • Ensure that claims are submitted in a timely manner and meet all deadlines
  • Verify that claims have been processed correctly and appeal any denied claims.
  • Review provider contracts to ensure that billing and coding comply with the terms of the agreement’
  • Prepare reports on audit findings and present them to management.
  • Prepare supporting documents and reports for disputes and queries on patient management from HMO and corporate organizations.
  • Participate in preparing and reviewing SOP of the Department. Serve as a resource to other departments on billing and coding issues.
  • Perform other adhoc duties as assigned

Required Skills

  • Good Knowledge of Managed Care/HMO Processes and Principles.
  • Good Knowledge of Process of Claims making/Claims submission.(Able to use different HMOs online claim submission portal).
  • Good Negotiating skill
  •  Good knowledge of claims reconciliation process.
  • Ability  to engage HMOs on all HMO's operational issues. Eg . Tariff review, enrollees complaints, Claims issues etc
  • Well-grounded in NHIA operational guideline.
  • Effective communication skill
  • Good Constructive Written Skill
  • Problem solving Skill.

Method of Application
Interested and qualified candidates should send their CV to: career@dedahospital.com or hrdedahospital@gmail.com using the Job Position as the subject of the mail.