Care Coordinator (HMO Medical Review)

About the role

The Care Coordinator oversees and coordinates the medical care of members so that healthcare services are appropriate, timely and high quality, in line with the HMO's clinical guidelines and policies. The role covers clinical review, care planning, provider engagement and medical decision-making, working with providers, internal teams and members to ensure continuity of care and adherence to approved benefits. Complex medical issues are escalated to the Senior Medical Officer.

Key responsibilities

• Review and coordinate care for members needing medical oversight, including admissions, referrals and specialist care, and monitor ongoing treatment plans and outcomes
• Assess clinical information to determine medical necessity and appropriateness of proposed treatments, and give clinical guidance in line with approved protocols
• Conduct medical reviews for authorizations, admissions, procedures and high-cost treatments, and identify inappropriate utilization
• Liaise with hospitals, clinics and specialists, clarify treatment plans and act as clinical point of contact for members with complex needs
• Maintain accurate medical records, care notes and authorization decisions, prepare clinical reports and take part in audits and quality improvement
• Uphold confidentiality and data protection, reporting suspected breaches promptly
• Carry out other assigned duties, take part in departmental knowledge sharing and support the Head of Information Technology as required

Required profile

• Bachelor of Medicine, Bachelor of Surgery (MBBS or equivalent)
• Fully registered with the Medical and Dental Council of Nigeria (MDCN) with a valid practicing license
• Minimum of 3-5 years' post-qualification experience, preferably in an HMO, hospital or managed care setting

Required skills

• Ability to assess medical necessity and treatment plans independently
• Good understanding of managed healthcare and HMO operations
• Excellent communication and interpersonal skills
• Accurate, thorough and timely documentation of medical decisions
• Ability to interpret clinical data and identify trends, risks and cost-effective care solutions
• Building effective relationships with providers and resolving conflicts professionally