Manager - Inspections
Jobs at:National Health Insurance Management Authority (NHIMA)
Deadline of this Job:
09 November 2021
Within Zambia , Lusaka , South - Central Africa
Date Posted: Thursday, October 21, 2021 , Base Salary: Not Disclosed
This role is responsible for implementing and maintaining NHIMA’s accredited facilities Inspections and Clinical Audit strategy to ensure compliance with quality protocols in line with the NHI ACT No 2 of 2018.
Reporting to the office of the Director Quality Assurance and Accreditation, the role will ensure that Clinical Inspection and Clinical audit policy is implemented including monitoring and reporting, investigating incidents and defining and enforcing corrective measures. The role will require extensive travel within Zambia as part of the inspections processes.
Stakeholder & Facilities Outcomes
• Lead a team of Clinical Case Inspectors and subject matter experts to define variety of clinical protocol standards that they will plan assess, inspect, report and evaluate based on evidence-based, person-centred care,
• To manage and implement the process of retrospective clinical Inspections and clinical audits, including billing practices of high-risk accredited providers,
• To support in concurrent case review and case management,
• To provide clinical support and guidance to fraud investigation activity,
• To provide clinical support and guidance to health risk analysis activity,
• To help develop, maintain, update a tracker of inspections findings from all accredited health care providers,
• Ensures all records of inspection process are filed and stored at NHIMA, and
• Recommending for suspension or revocation of accreditation of health care providers who do not meet the minimum quality standards.
Finance & Solvency Outcomes
• To implement processes to recover overcharging and billing errors identified after inspection of facilities,
• Follow-up the recovery process related to the audited provider with NHIMA’s Claims department until completion,
• To implement processes to monitor utilisation of claims advance payments to accredited facilities,
• Ensure auditing of usage, utilisation of medical equipment in line with Medical Equipment Policy of NHIMA,
• Participate in the development of departmental revenue and expenditure estimates; and
• Managing inspection activities within set cost parameters.
Staff & Learning Environment Outcomes
• To organise and prioritise workload of the team by assigning clinical inspectors for each targeted area,
• To supervise and support a team of clinical inspectors to plan, assess, implement and report on clinical inspections while ensuring that the documentation is maintained and updated,
• To identify the training needs of clinical inspectors and direct, coordinate and supervise the development of their competency and professional skills through teaching, training, mentoring and support,
• Oversees that Inspectors personnel have the appropriate education and experience, receive the appropriate training for the type and complexity of the services offered including continuing professional development to improve skills and knowledge,
• Ensuring optimal staffing levels in the unit to meet inspection needs of the department; and
• In charge of staff development, and performance management and staff career development in the department.
Predictable Systems and Control Outcomes
• Conduct data driven on-site clinical inspections and audits of accredited healthcare service providers, checking and evaluating accurately the medical record and related documents of the members to assess any discrepancy in clinical protocols, prescribing practices, preauthorization, case management, the billing of services or regarding the justification of the procedure(s),
• Investigate suspected health insurance misuse and abuse cases related to NHIMA members, collecting necessary documentation and as required, evidence to support the evaluation of the case,
• Prepare the final Clinical inspection or clinical audit report following the on-site audit and investigation; communicate with the providers regarding the audit findings and initiates the corrective adjustments, if any,
• Ensure that inspections and processes are documented in a professional manner with due confidentiality,
• Understand all policies and procedures relevant to the claims cycle , complaints and claims advance policy for accredited providers, liaise regularly with the relevant departments to understand current provider issues and observed billing trends,
• Profile accredited providers, use statistical analysis of provider behaviour prepared , and commission specific data analysis as required by clinical inspection and audit plan
• Implement relevant internal procedures, processes and practices that minimizes the Authority’s risks of dealing with accredited health care providers.
• Undertaking any task/assignment which the supervisor may delegate from time to time.
Knowledge, Skills, Qualifications and Experience
• Must have Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language.
• A Bachelor’s Degree in Medicine and Surgery degree, A degree in clinical medicine, pharmacy or its equivalent from a recognized training institution.
• A postgraduate degree in Management, Business Administration, Public Health, Clinical Medicine, or its equivalent will be an added advantage
• Must have at least 5 years in a similar role
Competencies required for this Role
• Must be familiar with the tools of monitoring and evaluation as part of the inspection processes.
• Must be familiar with accepted general health and medical standards in Zambia;
• Track record of achieving targets with a consistent high level of quality.
• Ability to liaise with different teams and at different management levels; and
• Must have strong leadership skills and able to lead teams effectively.
Work Hours: 8
Experience in Months: 60
Level of Education: Bachelor Degree
Job application procedure
Please click here to apply.