The Role
The Case Manager will conduct comprehensive clinical case reviews at specified healthcare facilities, prioritizing the detection of fraud, waste, and abuse while performing morbidity and mortality audits. This role ensures adherence to clinical standards, ethical principles, and cost-effectiveness benchmarks in care delivery. Additionally, the Case Manager delivers objective, evidence-based clinical perspectives to inform decision-making processes, free from any commercial influence.
What You’ll Do
Perform comprehensive clinical assessments directly at designated healthcare facilities to ensure adherence to established protocols and standards.
Conduct a thorough evaluation of patient cases to determine clinical appropriateness, evaluate the quality of care provided, and verify compliance with established standards.
Conduct morbidity and mortality reviews to assess patient outcomes and uncover avenues for enhancement in clinical care.
Deliver well-organized, data-driven recommendations based on thorough clinical reviews and comprehensive audits.
Examine and detect instances of unwarranted, excessive, inappropriate, or fraudulent healthcare service patterns.
Investigate allegations of fraud, waste, and abuse within healthcare facilities, meticulously collecting and recording findings to ensure accuracy and thorough documentation.
Critical issues and high-risk findings must be promptly communicated to the relevant internal stakeholders for timely resolution and risk mitigation.
Deliver objective clinical assessments and informed recommendations grounded in reviewed cases and the most current evidence available.
Develop comprehensive reports and documentation after conducting facility visits and case evaluations.
Provide expert guidance and actionable recommendations to internal teams regarding intricate clinical cases and critical healthcare delivery challenges.
Professionally interact with healthcare providers and representatives of healthcare facilities to conduct reviews and investigations.
Uphold professional autonomy, impartiality, and discretion in the execution of assigned responsibilities.
Partner with clinical, operations, and quality teams internally to advance organizational objectives and enhance healthcare outcomes.
Ensure adherence to relevant clinical guidelines, ethical standards, medical regulations, and internal organizational policies.
To remain abreast of the latest clinical standards, healthcare regulations, and industry best practices pertinent to case management initiatives, continuous professional development is essential.
Candidates must meet the following criteria to be considered for this role. A bachelor’s degree in a relevant field, such as business administration or computer science, is required, along with at least three years of professional experience in a similar position. Proficiency in Microsoft Office Suite and strong communication skills are essential. Familiarity with project management software and experience leading cross-functional teams are highly desirable. The ability to work independently, meet deadlines, and adapt to changing priorities is crucial.
What You’ll Bring
A Bachelor of Medicine, Bachelor of Surgery (MBBS or an equivalent qualification) or a Bachelor of Nursing (BNS) is required for this position.
A current, unrestricted medical or nursing license permitting practice 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 within the healthcare field.
Proven expertise in conducting clinical audits, performing detailed case reviews, or delivering hands-on hospital practice.
Maintains unwavering integrity and strictly adheres to established medical ethics standards.
Possesses exceptional analytical capabilities and a proven aptitude for generating comprehensive reports.
Demonstrated capacity to operate autonomously within remote, field-based settings.
Compliance Requirements include ensuring adherence to all applicable laws, regulations, and internal policies governing the organization’s operations. The role demands a thorough understanding of regulatory frameworks relevant to the industry, as well as the ability to interpret and apply complex legal requirements effectively. Responsibilities encompass monitoring changes in compliance standards, conducting risk assessments, and implementing corrective actions as needed. Additionally, the position requires collaboration with cross-functional teams to foster a culture of compliance and integrity throughout the organization. Proficiency in compliance software tools and regulatory reporting is essential to maintain operational transparency and mitigate potential risks.
A clean record free of any felony convictions or misconduct involving patient care, controlled substances, or violations of professional trust is mandatory.
All active or pending investigations that could impact license or professional practice must be disclosed.
Nice to Have
Professional experience in health insurance operations, claims adjudication processes, or utilization management methodologies is required.
Individuals with prior experience in investigating cases involving fraud, waste, and abuse are strongly encouraged to apply. Proficiency in reviewing financial records, interviewing witnesses, and analyzing evidence is essential for this role. Familiarity with regulatory compliance standards and investigative methodologies will be highly valued. Candidates should demonstrate a keen attention to detail and the ability to document findings accurately and thoroughly.
Interested candidates should submit their application through the designated method outlined for submissions. Kindly follow the specified procedure to ensure your application is received and processed promptly. For detailed instructions, refer to the designated section within the application portal. Ensure all required documents are attached as per the outlined guidelines to avoid any delays in the review process.
Please utilize the provided link(s) to submit your application through the company’s official website.
Qualifications
BA/BSc/HND
Experience Required
3 years
