The Role
The Case Manager will conduct clinical case reviews at specified healthcare facilities, prioritizing the detection of fraud, waste, and abuse while performing morbidity and mortality audits. This position ensures adherence to clinical standards, ethical principles, and cost-efficiency benchmarks in care delivery. The role delivers independent, evidence-based clinical perspectives to inform decision-making, free from commercial influence.
What You’ll Do
Perform on-site evaluations of clinical operations at designated healthcare facilities to ensure adherence to established standards and protocols.
Conduct thorough evaluations of patient cases to determine clinical appropriateness, evaluate the quality of care provided, and ensure compliance with established standards.
Conduct morbidity and mortality audits to assess patient outcomes and pinpoint areas where care can be enhanced.
Deliver well-organized, fact-supported recommendations grounded in thorough clinical evaluations and systematic audits.
Analyze healthcare service utilization to detect instances of unnecessary, excessive, inappropriate, or potentially fraudulent practices.
Investigate potential incidents of fraud, waste, and abuse within healthcare facilities, ensuring thorough documentation of findings for further review and action.
Critical issues and high-risk findings must be promptly communicated to the relevant internal stakeholders for timely resolution and risk mitigation.
Deliver well-reasoned clinical evaluations and actionable guidance grounded in case reviews and current evidence.
Prepare comprehensive reports and detailed documentation after on-site facility evaluations and case assessments.
Provide expert counsel and actionable guidance to internal teams regarding intricate clinical cases and healthcare delivery challenges.
Engage professionally with healthcare providers and facility representatives during reviews and investigations
Ensure professional autonomy, impartiality, and discretion are upheld throughout the execution of assigned responsibilities.
Partner with clinical, operational, and quality teams across the organization to help advance strategic objectives and enhance healthcare delivery.
Maintain adherence to relevant clinical guidelines, medical ethics standards, regulatory mandates, and internal organizational policies.
To remain current with evolving clinical standards, healthcare regulations, and leading industry practices pertinent to case management operations, continuous professional development is essential.
Seeking a detail-oriented individual to join our team, with a proven ability to collaborate effectively in a fast-paced environment. The ideal candidate must possess strong communication skills, both written and verbal, alongside exceptional problem-solving capabilities. Applicants should demonstrate proficiency in relevant software and tools, along with a minimum of two years of experience in a related field. Additionally, the role requires the capacity to manage multiple priorities, meet deadlines consistently, and maintain a high level of accuracy. A bachelor’s degree in a pertinent discipline is also essential for consideration.
What You’ll Bring
A Bachelor of Medicine, Bachelor of Surgery (MBBS or equivalent qualification) or a Bachelor of Nursing (BNS) is required for this position.
A current, unrestricted medical or nursing license permitting practice anywhere in Nigeria is required.
A minimum of three years of hands-on clinical practice is required.
Demonstrates a comprehensive grasp of clinical guidelines and established standards of care.
Proven expertise in conducting clinical audits, performing comprehensive case reviews, and engaging in hands-on hospital practice is required.
Demonstrates unwavering integrity and a steadfast commitment to upholding medical ethics.
Proven expertise in data analysis and the creation of comprehensive reports is required. Candidates must demonstrate exceptional ability to interpret complex information and present findings clearly and effectively.
Demonstrates a strong capacity for autonomous work in remote or on-site field settings, handling tasks and responsibilities with minimal supervision while maintaining productivity and adaptability to changing conditions.
Compliance Requirements include ensuring adherence to all relevant regulatory standards, internal policies, and industry best practices. The role demands meticulous attention to detail to accurately interpret and implement legal and organizational guidelines. Candidates must possess a strong understanding of compliance frameworks and the ability to assess risks and mitigate potential violations. Proficiency in documentation, reporting, and audit preparation is essential to maintain organizational integrity and regulatory alignment.
Applicants must have a clean professional record with no prior felony convictions or misconduct incidents connected to patient care, the handling of controlled substances, or violations of professional trust.
All ongoing or pending investigations that could impact license or professional practice must be disclosed.
Nice to Have
Professional candidates should possess prior experience in the health insurance sector, specifically in claims review or utilization management roles.
Professional experience investigating matters pertaining to fraud, waste, and abuse is essential.
go to method of application
To initiate your application, please utilize the provided link(s) on the company’s official website.
Qualifications
BA/BSc/HND
Experience Required
3 years
