Job Summary

The role is responsible for implementing NHIMA’s accredited facilities Inspections, Clinical and Claims 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/Claims 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 process.

Key Responsibilities

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

Stakeholder & Facilities Outcomes

• Provide technical oversight to clinical/claims audits of accredited healthcare facilities, and reporting.
• Ensure accredited HCPs comply with Clinical Guidelines/Protocols and Standards.
• Monitor and Evaluate adherence to NHIMA Claim Guidelines and Protocols,
• Facilitate and provide technical input stakeholder engagement activities aimed at enhancing quality of insured health services provided,
• Recommend for post audit relevant suctions to health care providers.
• Communicate findings and recommendations of clinical/claims audits to Director Quality Assurance and Accreditation, Management Accreditation committee, QAA committee of the board, Ministry of Health, accredited facility and other relevant bodies.

Finance & Solvency Outcomes

• Facilitate clawback of fraudulent and erroneously claimed reimbursements,
• Development of Clinical Inspections Unit Annual Work Plan,
• Provide technical oversight to the quarterly monitoring and evaluation of Annual Work Plan implementation
• Provide input to the QAA Departmental Annual Work Plan
• Represent the Unit in 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

• Design and implement customised data collection tools for clinical audit and fraud investigations using relevant background information and criteria,
• Monitor and Evaluate claim data to identify potential clinical/claims audits,
• Maintain clinical/claims audit database and audit reports,
• Identify and implement relevant internal control procedures to safeguard the Authority Fund,
• Undertake any task/assignment which the supervisor may delegate from time to time.

Education Requirements

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, A degree in Clinical Medicine, Pharmacy or its equivalent from a recognized training institution.
• A postgraduate degree in Project 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

Required Skills

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 and supervisory skills and able to lead teams effectively.

• Provide technical oversight to clinical/claims audits of accredited healthcare facilities, and reporting.
• Ensure accredited HCPs comply with Clinical Guidelines/Protocols and Standards.
• Monitor and Evaluate adherence to NHIMA Claim Guidelines and Protocols,
• Facilitate and provide technical input stakeholder engagement activities aimed at enhancing quality of insured health services provided,
• Recommend for post audit relevant suctions to health care providers.
• Communicate findings and recommendations of clinical/claims audits to Director Quality Assurance and Accreditation, Management Accreditation committee, QAA committee of the board, Ministry of Health, accredited facility and other relevant bodies.
• Facilitate clawback of fraudulent and erroneously claimed reimbursements,
• Development of Clinical Inspections Unit Annual Work Plan,
• Provide technical oversight to the quarterly monitoring and evaluation of Annual Work Plan implementation
• Provide input to the QAA Departmental Annual Work Plan
• Represent the Unit in 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.
• Design and implement customised data collection tools for clinical audit and fraud investigations using relevant background information and criteria,
• Monitor and Evaluate claim data to identify potential clinical/claims audits,
• Maintain clinical/claims audit database and audit reports,
• Identify and implement relevant internal control procedures to safeguard the Authority Fund,
• Undertake any task/assignment which the supervisor may delegate from time to time.

• 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 and supervisory skills and able to lead teams effectively.

• 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, A degree in Clinical Medicine, Pharmacy or its equivalent from a recognized training institution.
• A postgraduate degree in Project Management, Business Administration, Public Health, Clinical Medicine, or its equivalent will be an added advantage