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

The key functions of the role will include but not limited to;

A. 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

B. 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.

C. 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 behaviour 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 2 years of 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.