Head of Medicals

Responsibilities:

Medical and Clinical Oversight:

• Provide professional leadership and direction to the medical team.
• Oversee medical case reviews, utilization management, and claims adjudication.
• Ensure adherence to clinical protocols, evidence-based medicine, and NHIA standards.
• Review and approve pre-authorizations, referrals, and complex medical cases. 
  

Provider Network Management:

• Supervise accreditation and re-accreditation of healthcare providers.
• Conduct periodic provider assessments and performance reviews.
• Maintain effective relationships with hospitals, clinics, and diagnostic centers.
• Ensure provider compliance with contractual terms and service quality standards. 
  

Quality Assurance and Clinical Governance:

• Develop and implement quality assurance frameworks and clinical audit systems.
• Lead investigations into medical complaints, grievances, and service failures.
• Promote continuous improvement in healthcare outcomes and member satisfaction.
  

Health Policy and Strategic Support:

• Contribute to strategic planning and development of health programs and packages.
• Advise management on clinical trends, emerging health issues, and operational improvements.
• Lead staff training and health education initiatives for internal teams and partners.
  

Regulatory Compliance and Reporting:

• Ensure full compliance with NHIA, the Ministry of Health, and other regulatory bodies.
• Prepare periodic medical reports, utilization analyses, and clinical performance dashboards.
• Represent the organization in technical and regulatory meetings when required.

Requirements:

• Minimum of 4 years of post-qualification experience, including at least 2 years in a senior medical or management role within an HMO or healthcare institution.
• Proven experience in utilization management, clinical governance, and provider relations.
• Strong understanding of NHIA operations, HMO processes, and healthcare financing models in Nigeria.
• Quality of healthcare delivery and provider performance metrics.
• Timely adjudication and resolution of claims and pre-authorizations.
• Compliance with NHIA standards and regulatory requirements.
• Customer and provider satisfaction indices.
• Effective utilization and cost management outcomes.