Senior Specialist, Health Insurance

Ministry of Public Health - Qatar; Doha; On-site; QAR 400,000 - 600,000; Full time

Job summary

A leading government entity in Qatar seeks a Compliance Officer to oversee healthcare provider compliance within the National Health Insurance Scheme. The role involves developing policies, monitoring compliance, and engaging with stakeholders to ensure regulatory adherence and improve healthcare services. Candidates should possess a relevant Bachelor's degree and extensive experience in healthcare regulation.

Qualifications

• Minimum 7 years in healthcare or related fields.
• At least 3 years in supervisory roles.
• Bachelor's degree in relevant health service fields.

Responsibilities

• Monitor compliance of healthcare providers within NHIS.
• Develop policies and procedures for healthcare regulations.
• Conduct investigations and report non-compliance.

Skills

Compliance Monitoring

Stakeholder Engagement

Policy Development

Data Analysis

Fraud Detection

Education

Bachelor's Degree in Medicine (MD)

Health Informatics Management

Health Economics

Healthcare Management

Job description

Job Summary:

The job holder shall oversee compliance of regulated bodies and healthcare providers, collaborate with stakeholders within the Ministry of Public Health (MOPH) and externally to develop policies and procedures aligned with industry standards, and maintain relationships with healthcare providers, insurers, and the scheme network. The role involves analyzing, evaluating, and finalizing applications from healthcare providers to operate within the National Health Insurance Scheme (NHIS) as per HFID guidelines. Additionally, the job includes creating and implementing detection, recovery, and prevention processes to reduce unnecessary medical expenses and ensure regulatory compliance.

Roles and Responsibilities:

1. Monitor compliance of regulated bodies and healthcare providers within NHIS.
2. Report non-compliance to the Head of Section and conduct investigations.
3. Build and maintain strong relationships with internal and external stakeholders.
4. Create databases and records for accurate record-keeping and audits.
5. Develop policies and procedures to enforce healthcare regulations.
6. Establish standards and processes to ensure provider quality, appropriate services, and patient safety, in coordination with MOPH departments.
7. Define application, registration, audit, and renewal processes for healthcare providers under HFID.
8. Manage and organize information for accessibility and cross-departmental use.
9. Implement frameworks for contracting and negotiations.
10. Establish frameworks for coding and reimbursement mandates.
11. Develop criteria to monitor the performance of regulated bodies and providers based on KPIs, KRAs, and KPAs.
12. Create mechanisms to detect and address fraud, waste, and abuse among providers.
13. Develop frameworks for claims recovery and reconciliation.
14. Conduct on-site inspections as necessary.
15. Investigate and analyze potential fraud, abuse, and waste instances.
16. Identify industry best practices for continuous improvement.
17. Support and deliver training programs for healthcare providers, insurance companies, and TPAs.
18. Supervise tender preparations in coordination with administrative units and authorities.
19. Set operational plans for private sector participation in health services, monitor implementation, and evaluate outcomes.
20. Engage stakeholders to identify and manage risks, and promote governance and control measures.
21. Make necessary calls to facilitate outcomes during and outside working hours.
22. Analyze activity data trends and benchmark against key performance measures.
23. Attend meetings, conferences, and workshops; deliver presentations on relevant issues locally and internationally.
24. Perform additional duties as required to meet organizational needs.

Required Education:

Bachelor's Degree in Medicine (MD), Health Informatics Management, Health Economics, Health Policy and Funding, Healthcare Management, Pharmacy/D, Regulations/Legal in health settings, or related health service fields.

Required Experience:

Minimum 7 years in healthcare, health insurance, government regulation, or related fields, including at least 3 years in supervisory roles.