NHIMA
The National Health Insurance Management Authority (NHIMA) is the Statutory Body charged with the mandate of managing the National Health Insurance Scheme (NHIS) on behalf of the Government of the Republic of Zambia (GRZ) as provided by the National Health Insurance Act No. 2 of 2018. The National Health Insurance Management Authority (NHIMA) promotes the growth of the social health protection sector in its quest to contribute toward the attainment of Universal Health Coverage (UHC).
As part of the operationalisation of the scheme, the Authority now wishes to recruit the underlisted role.
1. Manager Revenue Accounting
Job Purpose
This is a Senior Management role responsible primarily for maximizing the Authority’s opportunity for Contributions Collections and General Revenues i.e., Accreditation Fees. To do that, the Manager Revenue Accounting shall compile and analyze data for Management decision making.
It is also expected that the jobholder will apply the most current accounting and finance standards (IFRS) and rules in the execution of duties making financial statements credible and allowing for more economic decisions based on accurate and consistent information. The holder of this senior Management Role shall report to the Director Finance & Investments.
Key Responsibilities
The key functions of the role will include but not limited to;
Member Experience & Stakeholder Engagement
Membership Experience
⦁Establishing strategic Partnerships and supporting initiatives to growing membership across all Sectors to achieve Universal Health coverage in line with NHIMA’s mandate.
Stakeholder Engagement
⦁Developing strategies that ensure continuous engagement NHIS members and retention across all sectors.
⦁Establishing through a structured Strategy a regular plan to ensure members’ contributions are timely accounted for hence guaranteeing access to healthcare services under the NHIS.
⦁Ensuring that Resources are available to functional departments to retain and grow membership into the scheme.
Finance Sustainability & Scheme Solvency
⦁Ensuring that contributions are collected through appropriately devised strategies/methodologies.
⦁Assisting in the preparation of year-end Financial Statements by ensuring compliance reporting in line with the appropriate accounting standards for all revenue transactions including disclosures in accompanying notes.
⦁Coordinating with Relationship managers to prepare annual revenue budgets for both the Fund and the Authority and seeking relevant approvals before implementation.
⦁Preparing internal management accounts including Revenue Projections to aid day to day decision making.
⦁Optimizing returns from investment of surplus cash resources for attainment of appropriate operating cover.
⦁Broadening the Authority’s revenue base by bringing on Board non-traditional revenue streams other than contributions.
⦁Effectively reconciling all Account Receivables, identifying and analyzing issues providing Management with insight into large or unusual fluctuations.
Staff & Learning Environment
⦁Ensuring that adequate staff are recruited in the Revenue Function in line with the approved structure,
⦁Ensuring staff under his\her supervision are appropriately inducted, motivated, and trained,
⦁Implementing a performance management system for staff in the Revenue Unit.
Identifying and evaluating opportunities for process improvements to gain revenue collection efficiencies and the flow of financial information.
Predictable Systems, Processes and Risk Management
⦁Facilitating, co-ordinating the design and development of Authority systems that will enable comprehensive collection of Contributions and other Authority revenues/receivables.
⦁Managing all risks associated with contribution collections.
⦁Assisting in the resolution of all revenue related internal & external audit queries.
⦁Putting up remedial actions for all gaps identified in audits,
⦁Establishing internal controls to enhance accountability in the utilization of contributions.
⦁Performing all other tasks and assignments as may be delegated by the supervisor.
Knowledge, Skills, Qualifications and Experience
⦁Minimum of 7 years’ working experience in a similar role.
⦁Grade 12 certificate with 5 credits or better
⦁Bachelor’s degree in finance/accounting, ACCA, CIMA, ZICA
⦁Master’s degree in a business field is an added advantage.
⦁Demonstrable insurance work experience
Competencies required for this Role
⦁Must have high numeracy and sound technical skills
⦁Must be detail oriented and a highly organized self-starter;
Proficient in all Microsoft Office applications as well as medical office software and other relevant applications;
⦁Must have good commercial and business awareness
⦁Must have an analytical approach to work
⦁Must be an effective communicator
⦁Sound knowledge in social healthcare financing.
⦁Must have the ability to work as part of a team and to build strong working relationships including demonstrable experience in leading teams and ability to influence them to reaching the desired organizational objective.
2. Assistant Benefits And Claims Officer
Job Purpose
Reporting to the Senior Benefits and Claims Officer, the role will be responsible for the administration of claim submissions once they are sent through from the various accredited healthcare facilities. It will also be responsible for ensuring the submitted claims are paid out within the agreed service level agreements by ensuring timely submission to subsequent workflows and tracking the turnaround times within those workflows.
Key Responsibilities
⦁Daily Receiving and registration into claims register all new claims submissions from accredited Health Care Providers.
⦁Daily batching of all received claims from Health Care Providers.
⦁Documentation and tracking of all claims omissions emerging issues and timely engagement of Health Care Providers and Health Risk Management Unit.
⦁Under guidance of Supervisor, participate in claims movement tracker and preparation of daily and weekly reports.
⦁Measure performance of the various workflow turnaround times against agreed service level agreements.
⦁Manage filing and batching of various claim files.
⦁Participate in weekly claims adjudication schedule preparation and submission.
⦁Participate in claims post payment batching and risk audits in conjunction with Claims Reconciliation and Health Risk Units.
⦁As guided by supervisor, participate in claims scanning and indexing,
⦁Participate in any other claims process roles as demand arises and as guided by the Supervisor,
⦁Conduct any other roles as assigned by the Supervisor.
Knowledge, Skills, Qualifications and Experience
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language,
⦁Must have a Diploma or Degree in Healthcare Management or any related field,
⦁Certificate or Diploma in Health Insurance, Compensation fund or any social security being an added advantage,
⦁At least one (1) year working experience in a similar role.
Competencies required for this Role
⦁Extensive knowledge of the Insurance industry.
⦁Overall understanding of Health Care provider operations and medicine and treatment procedures.
⦁Financial acumen.
⦁Attention to detail, strong analytical and decision-making skills.
⦁Strong problem-solving and decision-making abilities, and ability to work under pressure,
⦁Good oral and written communication skills.
⦁Proficiency in office applications such as Excel, Word, PowerPoint, and many other relevant applications.
⦁Must have good interpersonal skills.
⦁Must have strong influencing and negotiation skills.
⦁Ability to work with limited supervision and highly organized.
3. Assistant Provider Reconciliation Officer (X3)
Job Purpose
Reporting to the Senior Health Risk Officer, the main role of the jobholder is to manage Health Care Providers (HCPs) claims and Finance/payment reconciliations by ensuring timely claim payments and reconciliations and identifying and correcting any discrepancies. The role will also be responsible for receiving and admission of claims in the claims register and ensuring timely correspondence with Health Care Providers on any omissions that are picked before claims are admitted on the claims register.
Key Responsibilities
Principle Accountabilities for this role include but are not limited to the following:
i. Claim settlements and reconciliations (40% weight)
⦁To verify totals on the received invoices and inform Health Care Providers by e- mail/letter of any differences by matching statements from Health Care Providers with batches on the claims register and physical claims
⦁Reconcile balances between Health Care Providers (HCPs) and NHIMA and maintain files for each Health Care Provider for returned bills to have quick and efficient access to HCP Queries.
⦁To reconcile all payments with Health Care Providers within 90 days of receiving settlement transfer advice.
⦁Follow up reconciliation statements submitted on a month-by-month basis,
⦁Prepare updated reconciliation statements for HCP Accounts on a weekly basis and submit Weekly, monthly, quarterly and adhoc reports to Supervisor.
⦁Preparation of Individual HCP Quarterly Reconciliation statements and submit to HCP after verification with Supervisor, every quarter and reconcile accounts within 15 days of submission to HCP.
⦁Prepare Sign off accounts records once reconciliation is agreed and completed and maintain report of Health Care Providers’ Sign offs for due reference as required.
ii. Health Care Provider Customer Care & Preliminary Claims Pre-assessment (60% weight)
⦁Receive claims from Health Care Providers and conduct quality check/preliminary claims assessment for obvious omissions immediately on submission for physically delivered claims and within 5 days for couriered and SFTP uploaded claims,
⦁Maintain emerging issues tracker to be shared as part of weekly reports for due intervention,
⦁Ensure any picked submission omissions are communicated to Health Care Providers within ten (10) days from received date,
⦁Admit all qualifying claims in the claims register immediately on receipt,
⦁Maintain good business relationship with Health Care Providers and conduct Health Care Provider sensitisation on NHIMA Benefits, Tariffs, and importance of properly filled in claim forms
⦁Post adjudication and post payment, actively timely engage Health Care Providers on claims submission omissions, incomplete and rejected claims, to avoid unnecessary disputes and disruptions in service provision due to non-payment of such claims.
⦁Maintain regular contact with Health Care Providers and any unpaid bills should be advised to the Health Care providers within 15 days after payment remittance notification by Finance.
⦁Participate in any other claims process roles as demand arises and as guided by the Supervisor
⦁Conduct any other roles as assigned by the Supervisor.
Knowledge, Skills, Qualifications and Experience
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language .
⦁Must have a Diploma or Degree in Healthcare Management or any related field.
⦁Certificate or Diploma in Health Insurance, Compensation fund or any social security being an added advantage.
⦁At least one (1) year working experience in a similar role
Competencies required for this Role
⦁Extensive knowledge of the Insurance industry.
⦁ Overall understanding of Health Care provider operations and medicine and treatment procedures.
⦁ Financial acumen.
⦁ Attention to detail, strong analytical and decision-making skills.
⦁Strong problem-solving and decision-making abilities, and ability to work under pressure,
⦁Good oral and written communication skills.
⦁Proficiency in office applications such as Excel, Word, PowerPoint, and many other relevant applications.
⦁Must have good interpersonal skills.
⦁Must have strong influencing and negotiation skills.
⦁Ability to work with limited supervision and highly organized.
4. Health Risk Officer
Job Purpose
Reporting to the Senior Health Risk Officer and the main purpose of the job is to provide sound risk management by working daily with other functional staff to assess potential and inherent or actual risks pertaining to the business and mainly related to Claims Management processes. This will involve analysing high-risk claims operations processes and building risk awareness amongst staff by providing support and training within the company.
Key Responsibilities
Principle Accountabilities for this role include but are not limited to the following:
i. Claims Management (60% weight)
⦁Coordinate the collection of risk information from source systems, departments and reports.
⦁Maintain a risk register for documenting risks and actions to manage each risk.
⦁Building risk awareness amongst staff by providing support and training within the function.
⦁Assist in the development and monitoring of key risk indicators (KRI) that are mapped to
various risks to determine elevations in risk and proactively implement risk mitigation measures.
⦁Periodically profile claims processes to ensure adherence to laid down claims business rules and standard Operating Procedures.
⦁Interrogate claims patterns from various claims data sources with an aim to identify outliers and put in place control measures.
⦁Working closely with Senior – Health Risk Officer, ensure availability of updated Unit
⦁Management Reports dashboards.
ii. Claim Settlements and Reconciliations (40% weight)
⦁Conduct 1st line Risk check of all Pre and Post Payment runs.
⦁Participant in Post payment run claims batching processes to help with timely primary identification of outliers.
⦁In close collaboration with Claims and Finance Reconciliation team, review all redirected bills and recoveries processes.
⦁In close collaboration with Claims and Finance Reconciliation team, participate in Provider training sessions, especially on risk mitigation issues.
⦁Prepare Weekly/Monthly & adhoc claims Risk Management status reports on to help timely intervention on any identified gaps.
⦁Participate in any other claims process roles as demand arises and as guided by the Supervisor
⦁Executing any other tasks and assignments that may be delegated by the supervisor from time to time.
Knowledge, Skills, Qualifications and Experience
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language.
⦁Must have a Degree in Healthcare Management or any related field.
⦁Certificate or Diploma in Health Insurance, Compensation fund or any social security is an added advantage.
⦁At least one (1) year working experience in a similar role.
Competencies required for this Role
⦁Extensive knowledge of the Insurance industry.
⦁Overall understanding of Health Care provider operations and medicine and treatment procedures.
⦁Financial acumen.
⦁Attention to detail, strong analytical and decision-making skills.
⦁Strong problem-solving and decision-making abilities, and ability to work under pressure
⦁Good oral and written communication skills.
⦁Proficiency in office applications such as Excel, Word, PowerPoint, and many other relevant applications.
⦁Must have good interpersonal skills.
⦁Must have strong influencing and negotiation skills.
⦁Ability to work with limited supervision and highly organized.
5. Manager Investments
Job Purpose
This is a Senior Management role which will particularly be responsible for ensuring growth and wealth creation of the National Health Insurance Fund (NHIF). The Investments Manager shall devise long & short-term strategies for acquiring, creating wealth, and disposing off portfolio holdings.
The job holder shall further be responsible for the identification and development of investment opportunities, pursuing and actualising revenue from alternative sources other than the contributions from the members and ensuring that all funds not immediately committed for operations are invested in high yielding but secure portfolios for the benefit of the members of the Fund.
The holder of this senior management role shall report to the Director Finance and Investments.
Key Responsibilities
The key functions of the role will include but not limited to;
Financial Sustainability and Scheme Solvency Outputs
⦁Prepare monthly, quarterly, and annual performance reports of the Fund in line with the Investment Policy.
⦁Coordinating investment programmes of the Authority to ensure that appropriate Authority resources are available and excess funds invested to enhance the Fund’s value in line with the investment objectives.
⦁Initiate activities, that grow the fund above the prescribed benchmarks in line with the strategic targets.
⦁Monitor performance of the Fund and ensure compliance with the Investment Policy across all classes of investments.
Member Experience and Stakeholder Engagement Outputs
⦁Maintain a well-diversified portfolio of investment assets for the Fund’s financial sustainability,
⦁Formulating growth strategies, policies, procedures, and guidelines for the National Health Insurance Fund to ensure solvency of the Scheme.
⦁Identifying and developing structured investment product opportunities and alternative streams of revenue other than the contributions from members.
⦁Acting as a liaison officer between the Authority and Investee agencies.
⦁Coordinating all activities related to periodical and on-going operational research and actuarial valuations.
⦁Escalating any investment related matters that threaten the interest of the Authority.
⦁Developing and maintaining a good working relationship with Banks and Investment Houses for purposes of custody and placement of excess funds.
Organisational Capacity Outputs
⦁Ensuring that adequate staff are recruited in the Investments Unit in line with the approved structure,
⦁Ensure staff are inducted, motivated and trained for high performance tasks,
⦁Implement a performance management system for staff in the Unit,
⦁Perform other tasks as may be directed by the Director Finance & Investments.
Operational Excellence Outputs
⦁Review adequacy of existing investment guidelines/policies with a view to enhancing and ring fencing the investment portfolio;
⦁Responsible for Internal & external audits of the Authority on matters related to Investments,
⦁Implementing recommended measures Ensuring follow-up actions for all gaps identified in audits,
⦁Establishing internal controls in order to enhance accountability in the utilization of resource,
⦁Performing all other tasks and assignments as may be delegated by the supervisor.
⦁To monitor compliance with the relevant investment regulations so as to attain an optimum portfolio of investment assets.
⦁To assess the market conditions and keeping up to date with current statutory regulations and monitoring changes and developments in the industry and making recommendations to management on changes to investment and business strategies to ensure the Authority is responsive to changes in the environment.
⦁Ensure prudent fiscal and accounting controls are established for the Fund.
Knowledge, Skills, Qualifications and Experience
⦁Minimum of 7 years’ working experience in a similar role with strong focus on investment and business development.
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language.
⦁Bachelor’s degree in Accountancy, Business Administration, Finance, Economics, Mathematics, Quantitative Techniques, ACCA, ZICA, CIMA or any related degree.
⦁CFA and CFI professional qualification will be an added advantage
Competencies required for this Role
The ideal candidate is to have:
⦁Investment risk/ return appraisal skills;
⦁Strong business proposal writing skills;
⦁Exceptional negotiation skills;
⦁Must have strong financial analysis / interpretation capabilities;
⦁Ample knowledge regarding Financial analysis and financial markets;
⦁Must have portfolio management capabilities;
⦁Must be proficient in office applications such as Excel, Word, PowerPoint and other relevant Investment management information systems applications.
6. Internal Auditor
Job Purpose
This role reports to the Senior Internal Auditor and will be responsible for performing audits of functions and activities as assigned by the Senior Internal Auditor. Work will involve leading in the conduct of performance, financial and compliance audit assignments and providing consulting services to the Authority’s management and staff. It will also assist in assessing the adequacy and effectiveness of internal controls, governance and risk management processes.
Key Responsibilities
The key functions of the role will include but not limited to;
⦁Identify and recommend changes to the audit universe and participate in risk identification and assessment process and preparation of the risk-based Annual Audit Plan;
⦁Perform financial, operational and compliance audits of assigned functions, business processes, and application controls in supporting Information & Communications Technology systems including identifying and defining issues, developing criteria, reviewing and analysing evidence and documenting client processes and procedures,
⦁Develop the planning memo, preliminary survey and audit program for each audit assignment,
⦁Lead the audit team in execution of audit program during fieldwork including documenting, evaluating and testing systems and controls to determine their adequacy and effectiveness,
⦁Identify, develop, and document audit issues and recommendations using independent judgement concerning areas being reviewed,
⦁Prepare and maintain work papers, review working papers prepared by internal auditors, following up on the clearance of review points and evaluating the sufficiency and appropriateness of audit evidence to support conclusions drawn,
⦁Prepare the draft audit report reflecting an overview of the function reviewed, conclusions regarding the design and operating effectiveness of internal controls and operational efficiencies,
⦁Supervise and coach internal auditors throughout the audit with a view to ensuring conformity with the Standards,
⦁Follow up and report on implementation of internal and external audit recommendations in order to validate resolution of the issues,
⦁Develop and maintain productive client and staff relationships through individual contacts and group meetings,
⦁Performing audits procedures of business processes, functions and application controls in supporting IT systems, including identifying and defining issues, developing criteria, reviewing and analyzing evidence and documenting client processes and procedures,
⦁Appraise staff after each audit assignment, quarterly, semi-annual and annual basis, and
⦁Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to auditee.
Knowledge, Skills, Qualifications and Experience
⦁Bachelor of Accountancy or Full ACCA
⦁Grade 12 School Certificate with five (5) ‘O’ Levels with Credit or better which must include English and Mathematics.
⦁At least one (1) year working experience Internal or External Audit
⦁Certifications in CISA/CIA added advantage.
Competencies required for this Role
⦁Proficiency in applying internal auditing standards, procedures and techniques required in performing engagements;
⦁An understanding of management principles to recognize and evaluate the materiality and significance of deviations from best practices;
⦁Considerable knowledge of and skill in applying internal auditing and accounting principles and practices, and management principles and preferred business practices.
⦁Knowledge of the Standards for the Professional Practice of Internal Auditing and the Code of Ethics developed by the Institute of Internal Auditors;
⦁Knowledge of management information systems terminology, concepts and practices;
⦁Knowledge of industry program policies, procedures, regulations and laws;
⦁Skill in conducting quality control reviews of audit work products.
⦁Skill in collecting and analysing complex data, evaluating information and systems, and drawing logical conclusions;
⦁Considerable skill in planning and project management, and in maintaining composure under pressure while meeting multiple deadlines;
⦁Skill in negotiating issues and resolving problems;
⦁Considerable skill in using a computer with word processing, spreadsheet and other business software to prepare reports, memos, summaries and analyses;
⦁Considerable skill in effective verbal and written communications, including active listening skills and skill in presenting findings and recommendations;
⦁Ability to establish and maintain harmonious working relationships with co-workers, staff and external contacts, and to work effectively in a professional team environment;
⦁Considerable skill in assessing the effectiveness of internal controls over key IT risks, identifying significant exposures, analysing transactions and other management information and detecting changes in key risks and/or control effectiveness. Skill in developing appropriate recommendations to address exposures;
⦁Knowledge of generally accepted IS audit standards, statements and practices, and IS security and control practices; and
⦁Ability to learn new operations quickly and work independently is a must.
7. Senior Procurement Officer
Job Purpose
This role is responsible for procurement of goods, works and services in line with the Public Procurement Act and the Public Procurement Regulations for the effective and efficient functioning of the National Health Insurance Management Authority (NHIMA/Authority).
The role will ensure that the internal set up processes and the law are enforced by the Authority in the procurement of goods, works and services at a competitive price and value for money is attained.
Key Responsibilities
The key functions of the role will include but not limited to;
⦁Planning and organising the development of the Authority’s Annual Procurement plans to ensure that all departments submit their departmental plans in good time to the Procurement Department.
⦁Monitoring of performance of the Procurement Plan (Planned Activities against Actual) and giving periodical reports to Head Procurement and Supplies Department for onwards implementation by Management.
⦁Timely supervision and preparation of regulatory compliance reports for Submission to Zambia Public Procurement Authority (ZPPA).
⦁Organising NHIMA Procurement Committee (PC) meetings and ensuring that Procurement Committee papers are submitted to members in good time.
⦁Providing secretarial services to the NHIMA Procurement Committee in liaison with Head Procurement.
⦁Ensuring timely submission of NHIMA Procurement Committee Minutes to ZPPA
⦁Following up action on implementation of recommendations by the NHIMA PC.
⦁Ensuring suppliers and contractors deliver services as per agreed timelines.
⦁Monitoring of procurement of goods, works and services by NHIMA in the Public Sector to ensure transparency and accountability in the procurement process.
⦁Deciding on day-to-day operations and preparing individual work plan to ensure smooth implementation of programmes and activities for the Unit.
⦁Ensuring timely responses for all reports and clarifications requested by ZPPA.
⦁Maintaining a Risk Register and implementing mitigation measures in liaison with the Audit and Risk Department
⦁Maintenance of NHIMA Supplier Register
⦁Procurement of goods, services and works to ensure their timely availability.
⦁Ensuring that all procedures related to issuance, receiving, dispatching of materials are adhered to.
⦁Carrying out any lawful task as may be delegated by the supervisor.
Knowledge, Skills, Qualifications and Experience
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language;
⦁Degree in Purchasing and Supply with a valid practicing license;
⦁Demonstrable experience in procurement and supplies with at least 5 years in a procurement field.
Competencies required for this Role
⦁Must have high levels of integrity and ethics;
⦁Must have strong analytical and processing skills;
⦁Must be detail oriented and a highly organized self-starter;
⦁Must be an effective communicator; and
⦁Proficiency in office applications such as Word, Excel, PowerPoint and many other relevant applications;
8. Marketing Officer
Job Purpose
The role of the Marketing Officer is to provide support to the Public Relations department, other departments, and directorates at the National Health Insurance Management Authority (NHIMA). In addition, the officer will be required to assist in managing the Marketing, Communication and Branding activities for the Authority. The role requires a dynamic and creative professional to assist in the development, implementation enhancement of the NHIMA brand. The post holder will be expected to work across the entire marketing and communications brief covering branding, public relations, and marketing campaigns. This role will play an important part in ensuring that the NHIMA brand is presented consistently, campaigns are delivered to deadline, and that NHIMA remains visible to stakeholders and the public.
Key Responsibilities
The key functions of the role will include but not limited to;
⦁Supporting the Public Relations department’s initiatives with the planning, executing, and tracking of marketing programs.
⦁Coordinating marketing campaigns, including copy, posts, scheduling, testing, and database management.
⦁Monitoring and reporting on marketing campaigns especially in the informal sector.
⦁Assisting the Authority in the storage and distribution of NHIMA marketing materials to several stakeholders from time to time.
⦁Assisting the Head of the department in organising and managing events, trade shows, exhibitions etc when need arises.
⦁Ensuring swift and timely delivery of communications to target audiences.
⦁Writing and publishing relevant material for newsletter and other channels.
⦁Assisting in management of the brand building for NHIMA.
⦁Designing and development of awareness campaigns for brand positioning.
⦁Providing administrative support to coordinate and organize market/customer satisfaction research.
⦁Assisting in the development and distribution of marketing and promotional materials.
⦁Monitoring, analysing and collecting member complaint reports from the Customer Service department.
⦁Any other duties as assigned by the Supervisor.
Knowledge, Skills, Qualifications and Experience
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language; and
⦁Degree in Marketing, Public Relations, Communications or Journalism
⦁At least One (1) year experience in a similar role or closely related.
Competencies required for this Role
⦁Strong written and verbal communication skills.
⦁Must have proficient computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel); scheduling appointments/updating calendars.
⦁Capacity to work independently.
⦁Must have good interpersonal skills and organisational skills; and
⦁Must have excellent time management skills and ability to prioritize.
⦁Attention to detail.
⦁Ability to constantly improve and optimize.
9. Facility Inspections Officer
Job Purpose
The role will be responsible for performing clinical audits, health risk assessments and investigations, and on-site facility inspections of all accredited Healthcare Providers (HCPs) under the National Health Insurance Scheme (NHIS) To ensure compliance with NHIMA requirements, national standard treatment protocols, and other relevant regulatory and contractual obligations. The position will report to the Manager-Facility Inspections.
Key Responsibilities
Stakeholder and Facilities Outcomes
⦁Initiate, assess and recommend health facilities for assessment,
⦁Conduct on-site inspections and clinical audits of accredited healthcare facilities
⦁Ensure compliance to a variety of clinical protocol standards at all accredited Healthcare Providers (HCPs),
⦁Evaluate the quality of care provided, adherence to NHIMA protocols, including claims process, services provided, patient outcomes, infection control and staff qualifications.
⦁Review Medical records, claims and other documents to ensure compliance with regulations, standards, and contractual obligations.
⦁Keep accurate and detailed records of all inspections and audits conducted
⦁Regularly engage stakeholders to the satisfaction of all Authority policies and guidelines involving inspections, audits, fraud investigations and health risk,
⦁Participate in stakeholder engagement activities aimed at enhancing quality of insured health services provided,
⦁Study NHIS member feedback through customer satisfaction surveys and complaints committees to institute appropriate investigations in ailing accredited health facilities,
⦁Participate in the facilitation of all stakeholder tours, inspections and verification visits to accredited HCPs,
⦁Participate in the management and implementation of the process of retrospective clinical inspections and clinical audits, including billing practices of high-risk accredited providers and produce appropriate reports,
⦁Participate in the development of an annual audit programme which reflects the Authority’s priorities, and is delivered in line with agreed audit procedures,
⦁Write clear, concise and comprehensive clinical audit reports, suggest areas of good practice and where appropriate, propose recommendations to improve services.,
⦁Provide clinical support and guidance to fraud investigation activities,
⦁Participate in clinical fraud investigation activities,
⦁Provide clinical support and guidance to health risk analysis activity,
⦁Identify common areas of non-compliance and provide recommendations for process improvement within NHIMA and accredited healthcare providers
⦁Recommend for suspension or revocation of accreditation of health care providers who do not meet the minimum quality standards of care or are found in contravention of statutory and contractual obligations.
⦁Communicate findings and recommendations to Manager Facility Inspection, Management Accreditation committee, QAA committee of the board and accredited facility
Finance and Solvency Outcomes
⦁Participate in processes to recover overcharging and billing errors identified after inspection of facilities,
⦁Follow-up the recovery process related to the audited provider with Claims Department until completion,
⦁Participate in processes to monitor utilisation of Claims Advance Payments (CAP) to accredited facilities,
⦁Participate in auditing of utilisation of medical equipment in line with Medical Equipment Policy of NHIMA,
⦁Participate in the development of departmental revenue and expenditure estimates; and
⦁Participate in ensuring inspection activities are within set cost parameters.
Staff, Capacity Building and Learning Environment Outcomes
⦁Participate in all Unit and departmental trainings and continuous professional development to build dynamic capacity to conduct clinical audits and fraud investigations to assigned HCPs in line with the Authority policies.
Systems and Control Outcomes
⦁Participate in designing customised data collection tools for clinical audit and fraud investigations using relevant background information and criteria,
⦁Horizon-scan values, volumes, patterns and trends in the claims department to inform potential fraud investigations,
⦁Horizon-scan types and gravity of complaints in the complaints unit to inform the choice of HCPs to investigate in order to improve patient experience,
⦁Update and maintain the Clinical Audit Database in order to record Authority audit activity and facilitate reporting,
⦁Develop, maintain and update a tracker of inspections findings from all accredited HCPs,
⦁Investigate suspected health insurance misuse and abuse cases related to NHIS members, collecting necessary documentation and as required, evidence to support the evaluation of the case,
⦁Prepare the final clinical investigation or clinical audit report following the on-site audit and investigation; communicate with the providers regarding the audit findings and initiate the corrective adjustments, if any
⦁Profile accredited providers, use statistical analysis of provider behavior prepared, and commission specific data analysis as required by clinical investigation and audit plan.
Knowledge, Skills, Qualifications and Experience
⦁Grade twelve (12) School Certificate with at least 5 credits which should include English Language and Mathematics
⦁Degree in clinical medicine/ Pharmacy/ Nursing or equivalent qualifications.
⦁Registration with relevant regulatory body is required.
⦁Minimum of 1 year experience in a similar role.
Competencies required for this Role
⦁Must be willing to travel extensively,
⦁High level of professional integrity
⦁Able to write comprehensive and analytical reports,
⦁Must be an effective communicator with a good command of the English Language,
⦁Must possess effective investigative skills,
⦁Strong attention to detail
⦁Must be proficient in computer skills, including Microsoft Office Suite (Word, PowerPoint, and Excel); scheduling appointments/updating calendars,
⦁Must have knowledge and ability to operate basic office equipment such as printers, scanners,
⦁Must have good interpersonal skills and organisational skills, and
⦁Must have excellent time management skills and ability to prioritize.
To apply for this job please visit careers.nhima.co.zm.