Care Coordinator

Job title : Care Coordinator

Job Overview

The Care Coordinator is responsible for overseeing and coordinating the medical care of members to ensure appropriate, timely, and high-quality healthcare services in line with the HMO’s clinical guidelines and policies. The role involves clinical review, care planning, provider engagement, and medical decision-making to support effective utilization of healthcare services and positive member

• outcomes.
• The Care Coordinator works closely with healthcare providers, internal teams, and members to ensure continuity of care, proper clinical oversight, and adherence to approved benefits, while escalating complex medical issues to the Senior Medical Officer as required.

Key Responsibilities

Clinical Care Coordination

• Review and coordinate care for members requiring medical oversight, including admissions,
  referrals, and specialist care.
• Assess clinical information to determine medical necessity and appropriateness of proposed treatments.
• Support continuity of care by monitoring ongoing treatment plans and outcomes.
• Provide clinical guidance to members and providers in line with approved protocols.

Utilization Management & Clinical Review

• Conduct medical reviews for authorizations, admissions, procedures, and high-cost treatments.
• Ensure healthcare services align with benefit plans, clinical guidelines, and regulatory standards.
• Identify inappropriate utilization and recommend alternative, cost-effective care options where necessary.
• Escalate complex or high-risk cases to the Senior Medical Officer for further review

Provider Engagement & Member Support

• Liaise with hospitals, clinics, and specialists to facilitate effective service delivery to members.
• Clarify treatment plans, clinical decisions, and care pathways with providers as needed.
• Support Provider Relations by offering clinical input on quality-of-care issues and provider performance concerns.
• Serve as a clinical point of contact for members with complex medical needs.
• Support members in understanding their care plans, treatment options, and benefit coverage.

Documentation, Reporting & Quality Assurance

• Maintain accurate and complete medical records, care notes, and authorization decisions.
• Prepare clinical reports and summaries for internal review and management use.
• Ensure all clinical activities comply with NHIA regulations, company policies, and medical best practices.
• Participate in internal audits, clinical reviews, and quality improvement initiatives.

Data Protection & Confidentiality

• Uphold the highest standards of confidentiality in handling company-related information, ensuring compliance with data protection laws and internal policies.
• Adhere to the company’s information security guidelines, including proper storage, transmission, and disposal of sensitive materials.
• Promptly report any suspected data breaches or unauthorized access to the appropriate company authority.
• Participate in periodic data protection training to stay informed about evolving security risks and best practices.

General Assignment

• Execute any other duties and tasks that may be designated or assigned by the Company.
• Participate in the knowledge sharing programme of the department and the company
• To provide support to the Head of Information Technology as may be required towards serving the Board, Management, and staff.

Required Skills and Qualifications

Education

• 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.

Experience

• Minimum of 3–5 years’ post-qualification experience, preferably within an HMO, hospital, or managed care environment.

Skills & Competence

• Ability to assess medical necessity and determine appropriate treatment plans independently.
• Good understanding of managed healthcare and HMO operations
• Excellent communication and interpersonal skills
• Ensure accurate, thorough, and timely documentation of medical decisions and
  interactions.
• Interpret clinical data and identify trends, risks, and cost-effective care solutions.
• Build effective relationships with providers and internal departments; resolve
  conflicts professionally.

KPIs and Performance Metrics:

• Medical Review Accuracy: ≥ 98% of clinical authorizations and case reviews completed correctly, with minimal reversals or escalations.
• Follow-Up Timeliness: ≥ 95% of post-hospitalization or complex cases are followed up within the agreed timelines.
• Provider Engagement & Resolution: ≥ 90% of provider escalations addressed and resolved satisfactorily within SLA.
• Compliance & Documentation: 100% adherence to NHIA regulations, company policies, and complete, accurate clinical documentation.