BACKGROUND

The AVON HMO Case Manager is critical to achieving our business objectives by ensuring that the quality of patient management is significantly enhanced and enrollee satisfaction is maximized while promoting cost effectiveness. The successful candidate’s duties include assessing, planning, implementing, monitoring and evaluating actions required to meet the client’s health and human services needed

OBJECTIVES 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. 
  • Develops, coordinates, implements, and evaluates case management services to health plan enrollees/members and health care providers that contract with the HMO.
  • Collaborates with other staff in evaluating placement of members in proper primary care locations, developing and adapting forms and information systems, and mediating 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

  1. Maintains and supports the primary care provider and specialist network to the health plans by developing and maintaining training materials, leading small and large groups, 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. 
  2. 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, delegating and assigning job duties, leading biweekly case management meetings to review complicated cases, discussing and revising case management procedures, and informing case management staff of policy changes, providing educational opportunities, and analyzing and determining outcomes for difficult member and/or provider situations. 
  3. Assist in the development and implementation of a quality assurance and utilization review program.  Develops new policies and procedures and enforces existing standards. Constructs, evaluates, and revises forms in consultation with the Medical Services Director. 
  4. 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.
  5. 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.
  6. 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.   
  7. 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.
  8. Coordinate medical reviews, grievances and appeals. Develop review criteria and communicate with DMS to clarify coverage issues
  9. Ensure that client records are kept secure and confidential and maintained consistent with Health Department policies and procedures.  
  10. Perform other duties as assigned.

MINIMUM REQUIREMENTS

  • A fully qualified Doctor with minimum 3 years clinical experience. 
  • A minimum of 5-8 years’ experience inclusive of clinical experience, in a Managed Care/HMO variety of health care settings is required.  
  • Must have at least 4 years of supervisory experience.    
  • Must be a Registered Doctor in Nigeria with a valid practicing certification.   
  • Work in a standard office environment. Must attend meetings, seminars and speaking engagements throughout the County. 
  • Proven experience organizing and directing multiple teams and departments
  • Excellent & persuasive communicator – written and oral 
  • Extremely versatile, dedicated to efficient productivity
  • Experience in planning and leading the implementation of strategic initiatives 
  • Strong data analysis and reporting skills 
  • Discretion, display of good judgment

ADDITIONAL REQUIREMENTS

  • Nimble business mind with a focus on developing creative solutions 
  • Significant experience of conflict resolution and dealing with sensitive issues
  • Significant experience of working in a highly confidential environment
  • High levels of personal resilience and persistence and significant level of emotional intelligence
  • Experience in budget management

HOW TO APPLY