We are seeking a Senior Case Management Associate to help ensure that members with complex or high-risk health needs receive safe, timely, and well-coordinated care.
You will manage complex cases, identify risks to patient care, and work with doctors, hospitals, and internal teams to resolve problems and prevent delays in care.
You will also support the review of deaths, ICU and other high-risk admissions, and possible cases of fraud, waste, and abuse.
As a senior member of the team, you will guide junior case management staff and help improve how the team manages cases.
You will use patient and service data to identify problems and improve the quality, safety, and efficiency of care
What You'll Do
Manage complex, high-risk, and escalated cases to ensure patients receive safe, timely, and appropriate care.
Coordinate care with healthcare providers, emergency services, and internal clinical teams to resolve barriers and improve patient outcomes.
Monitor ICU and other high-risk admissions, ensuring timely interventions and appropriate care management.
Identify patient safety and clinical risks, take necessary action, and escalate concerns when required.
Maintain accurate documentation of case reviews, decisions, actions, and outcomes.
Review clinical quality complaints, adverse events, morbidity, and mortality cases, and ensure appropriate follow-up actions.
Conduct onsite clinical reviews at healthcare facilities, including the assessment of medical records and quality of care provided.
Monitor patient safety, quality, and care coordination issues across the provider network and recommend improvements.
Review claims, medical records, billing information, and other data to identify potential fraud, waste, and abuse (FWA).
Investigate suspected FWA cases in collaboration with providers, clinical teams, and other internal stakeholders.
Support the implementation of appropriate actions on confirmed FWA cases, including provider engagement and escalation where necessary.
Ensure all case reviews, investigations, and activities comply with company policies and applicable regulations.
Provide guidance, coaching, and technical support to junior members of the Case Management team.
Support team development by guiding colleagues through complex cases and strengthening their clinical judgement and case management skills.
Collaborate with Provider Management and other internal teams to resolve patient care issues and improve provider performance.
Maintain professional and independent clinical judgement when engaging with healthcare providers and other stakeholders.
Requirements
What You'll Bring
Bachelor of Medicine, Bachelor of Surgery (MBBS or equivalent) or Bachelor of Nursing Science (BNSc or equivalent).
Current and valid professional license to practice in Nigeria.
Minimum of 5 years of post-qualification clinical experience, with experience managing complex or high-risk patient cases.
Experience in case management, care coordination, clinical case review, or a similar healthcare role.
Experience reviewing medical records and applying clinical guidelines to assess the quality and appropriateness of patient care.
Willingness and ability to conduct field visits to hospitals and other healthcare facilities when required.
Must meet all company requirements for professional license verification, background checks, and disclosure of any restrictions or pending matters that may affect clinical practice.
Nice to Have:
Experience in health insurance, managed care, or healthcare operations.