Director, Beneficiary and Provider Management at National Hospital Insurance Fund (NHIF)

REF: NHIF/DBPM/002/23

Reporting to the Chief Executive Officer, the successful candidate will be responsible for overall leadership and oversight in the implementation of sustainable operational strategies related to member registration and retention, revenue collections, benefits management, case management, claims processing, quality assurance and policies for enhancing increased accessibility and quality healthcare for NHIF members and declared dependents geared towards Universal Health Coverage (UHC).

JOB PROFILE

Leadership and Advisory

• Lead the development, implementation, monitoring and review of sustainable operational strategies relating to member registration and retention, revenue collections, claims processing, case management and quality assurance;
• Lead stakeholder engagement activities that will enhance the achievement set targets in member registration, revenue collection, case management and claims processing;
• Oversee empanelment of health providers and ensure they are operating in line within the contracts and set industry and professional standards.
• Lead strategic purchasing initiatives.
• Lead a team of professionals within the directorate.

Stakeholder Engagement

• Provide technical advice to the Chief Executive Officer and Board of Management on issues of compliance, member registration, claims administration, healthcare provider surveillance, beneficiary satisfaction, disease patterns and trends;
• Engage with the stakeholders in the Public, Private and Sponsored Programs Sectors to identify and optimize on membership registration opportunities;
• Engage county governments and other potential partners in ensuring that all respective county residents have insurance membership with NHIF;

Healthcare Services

• Develop, enhance, and implement diagnosis, procedure, and other classifications;
• Develop, pilot, and implement prospective provider payment mechanisms;
• Define cost modelling methodology and required data sets and develop costing manual;
• Determine the prices of health care services, drugs and consumables based on developed costing manual;
• Prepare and educate the public on the prices of services, drugs and consumables included in the Health Care Benefits;
• Determine the method of drugs prescribing and determine the way of issuing of drugs covered by NHIF.
• Refine referral guidelines;
• Propose functions and funding for specific health services to be added to the NHIF on an incremental basis;
• Participate in the Health Needs Assessment for clinical interventions, pharmaceuticals and technologies with other responsible bodies;
• Compile the annual plan of needs for procurement of the Health Care Benefits;
• Participate in the Health technology assessment (HTA) for clinical interventions, pharmaceuticals and technologies with other responsible bodies;

Contracting and Empanelment

• Develop and implement performance based contracting methodology, including performance indicators, quality indicators, contract monitoring and payment terms;
• Administer contracts ensuring efficient process of preparing, signing, reviewing, adjustment and payment based on performance reports;
• Define standard operating procedures for the implementation of performance-based contracting, including contract performance monitoring, performance verification, payments, sanctions, grievance redress and contract renewal and modification;
• Train NHIF service providers’ staff in the procedure of contracting of service providers, monitoring contract performance, identifying challenges, performance-based payments, and costing.

Claims Management

• Develop and implement policies and strategies for effective and efficient management of claims;
• Ensure both employer and individual member accounts are managed properly;
• Collect, analyze, monitor and control reports/invoices from contracted health facilities;

Customer Care, Case Management and Quality Assurance

• Manage the process of receiving and processing complaints from Beneficiaries;
• Oversee the operations of the call centre;
• Perform preauthorization of benefits, concurrent review of patients undergoing treatment and post hospitalization reviews.
• Perform Beneficiary’s satisfaction surveys and undertake other diagnostic studies;
• Coordinate the production and dissemination of all monitoring and evaluation reports including statistical reports;
• Facilitate and undertake investigations of Beneficiary fraud and corruption.
• Facilitate investigations of Health Service Provider fraud and corruption. Policy Development
• Develop and implement strategies that enhance membership registration, retention and revenue growth;
• Develop and implement policies on regional and branch network expansion that will ensure NHIF services are accessible across the country;
• Develop and implement policies and strategies for effective and efficient case management and clinical audits;
• Develop and implement policies and strategies on business process re-engineering;
• Develop and implement policies on minimum acceptable quality benefits by healthcare facilities;
• Develop and implement strategies for enhancing increased accessibility to healthcare facilities by NHIF members and their declared dependants;

Information & Communication Technology

• Support development of Prospective provider reimbursement mechanisms in the operating ICT systems;
• Develop and implement medical procedure codes in the operating ICT systems;

Key competencies

• A strategic thinker with problem-solving, analytical, innovative and creative skills
• Proactive
• Ability to develop networks, alliances and collaborate widely to build and maintain strategic relationships.
• Strong acumen to effectively manage multiple stakeholders with diverse interests.
• Demonstrable professional and personal integrity
• Ability to persuade others, build consensus and gain cooperation.
• Strong experience in managing and building staff capabilities.
• Strong communication and interpersonal skills

Person Specifications

For appointment to this grade, an officer must have :-

• At least fifteen (15) years’ work experience five (5) of which should be in Senior management;
• Bachelor’s degree in economics, Business, Medicine, Social Science, Pharmacy, actuarial sciences or any other related field from a recognized Institution;
• Master’s degree in economics, Business, Medicine, Social Science, Pharmacy, actuarial sciences or any other related field from a recognized Institution;
• Professional qualification in actuarial science and membership will be an added advantage;
• Leadership and Management course lasting not less four (4) weeks from a recognized Institution;
• Proficiency in Computer Applications;
• Fulfil the requirements of Chapter 6 of the Constitution