Job Description
The Role
- The Case Manager will be responsible for conducting clinical case reviews at designated healthcare facilities, with a focus on identifying fraud, waste, and abuse, as well as performing morbidity and mortality audits. The role ensures that care delivery aligns with clinical standards, ethical guidelines, and cost-efficiency expectations. The Case Manager provides independent, evidence-based clinical insights to support decision-making without commercial bias.
What You'll Do
- Conduct on-site clinical reviews at assigned healthcare facilities
- Review patient cases to assess clinical appropriateness, quality of care, and adherence to established standards
- Perform morbidity and mortality audits to evaluate patient outcomes and identify opportunities for improvement
- Provide structured, evidence-based recommendations following clinical reviews and audits
- Identify patterns of unnecessary, excessive, inappropriate, or potentially fraudulent healthcare services
- Investigate suspected cases of fraud, waste, and abuse at healthcare facility level and document findings accordingly
- Escalate critical issues and high-risk findings to the appropriate internal stakeholders
- Provide independent clinical opinions and recommendations based on reviewed cases and available evidence
- Prepare detailed reports and documentation following facility visits and case reviews
- Support internal teams with insights and recommendations on complex clinical cases and healthcare delivery concerns
- Engage professionally with healthcare providers and facility representatives during reviews and investigations
- Maintain professional independence, objectivity, and confidentiality while carrying out assigned duties
- Collaborate with internal clinical, operations, and quality teams to support organizational goals and healthcare outcomes
- Ensure compliance with applicable clinical guidelines, medical ethics, regulatory requirements, and organizational policies
- Stay informed on current clinical standards, healthcare regulations, and industry best practices relevant to case management activities
Requirements
What You'll Bring
- Bachelor of Medicine, Bachelor of Surgery (MBBS or equivalent) or Bachelor of Nursing (BNS)
- Valid, unrestricted medical or nursing license to practice in Nigeria
- Minimum of 3 years of clinical practice experience
- Strong understanding of clinical guidelines and standards of care
- Experience in clinical audits, case review, or hospital practice
- High level of integrity and adherence to medical ethics
- Strong analytical and reporting skills
- Ability to work independently in field-based environments
Compliance Requirements:
- No history of felony or misconduct related to patient care, controlled substances, or professional trust
- Must disclose any ongoing or pending investigations affecting licensure or practice
Nice to Have
- Experience in health insurance, claims review, or utilization management
- Prior exposure to fraud, waste, and abuse investigations