Head of Medicals

Responsibilities:

• Lead and coordinate all medical and clinical activities across the HMO.
• Oversee provider network management, including onboarding, performance monitoring, and compliance checks.
• Supervise utilisation review, preauthorization, case management, and referrals.
• Ensure all clinical processes align with NHIA regulations and industry best practices.
• Work with the claims and quality assurance teams to resolve medical-related claims issues and drive quality improvement.
• Develop, review, and update clinical guidelines, protocols, and policies.
• Monitor service quality, patient outcomes, and provider performance metrics.
• Support investigations of clinical complaints and provide expert guidance on medical disputes.
• Lead medical audits and coordinate periodic assessments of provider facilities.
• Collaborate with management on health plans, benefit designs, and product development.
• Provide periodic medical reports, insights, and recommendations to executive leadership.

Requirements:

• MBBS or equivalent medical degree from a recognised institution.
• A valid medical license and registration with the Medical and Dental Council.
• At least 3 years post-qualification experience, including experience in HMOs, health insurance, or managed care.
• Strong understanding of NHIA guidelines, health financing, and provider reimbursement models.
• Proven ability to manage clinical teams and engage healthcare providers.
• Strong analytical skills with the ability to review medical documents and make sound decisions.
• Excellent communication, leadership, and interpersonal skills.
• High ethical standards, meticulous attention to detail, and a dedication to delivering quality care.