HMO Officer

Job Purpose

• The HMO Officer is responsible for managing all Health Maintenance Organization-related operations in the hospital.
• The role ensures smooth enrollment, authorization, claims processing, and relationship management between the hospital, HMOs, and patients to guarantee prompt service delivery and revenue collection.

Responsibilities

Patient Services & Eligibility

• Verify HMO patient eligibility and coverage using HMO portals before consultation/admission.
• Ensure proper registration and issuance of authorization codes for all HMO enrollees.
• Attend to HMO patients' complaints and guide them on benefits, co-pay, and exclusions.
• Liaise with clinicians to ensure treatment plans fall within HMO package guidelines.

Authorization & Claims Management

• Obtain pre-authorization for consultations, admissions, surgeries, and referrals within stipulated time.
• Prepare, collate, and submit claims to respective HMOs with complete supporting documents.
• Follow up on outstanding claims and ensure timely payment/reimbursement by HMOs.
• Track and reconcile HMO payments and deductions with hospital finance.

HMO Relations & Compliance

• Serve as the primary liaison between the hospital and all partner HMOs: AXA Mansard, Hygeia, Redcare, Avon, etc.
• Ensure the hospital complies with NHIA/HMO guidelines, service level agreements, and tariff structures.
• Attend HMO meetings, trainings, and audits on behalf of the hospital.
• Communicate policy changes, new tariffs, and benefit updates to clinical staff.

Reporting & Documentation

• Maintain an accurate database of all HMO patients, authorizations, and claims.
• Prepare weekly/monthly reports on HMO patient volume, revenue, outstanding claims, and challenges.
• Ensure proper filing and archiving of all HMO documents for audit purposes.

Requirements

• Education: HND/Bachelor's Degree in Health Administration, finance, Nursing, Public Health, or related fields.
• Experience: 1-5years' experience in an HMO, Hospital Corporate Services, or Insurance department.
• Knowledge: Good understanding of NHIA guidelines, HMO operations, and hospital billing processes.

Required Skills and Competencies

• Excellent communication and interpersonal skills
• Proficiency in Microsoft Excel, Word, and HMO portals
• Strong negotiation and problem-solving skills
• Attention to detail and good record-keeping
• Ability to work under pressure and meet deadlines
• Professionalism and patient-centered approach.