Senior Case Management Associate at Reliance HMO

The Role

• 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.
• Experience conducting clinical audits, mortality reviews, quality investigations, or patient safety reviews.
• Experience investigating fraud, waste, and abuse (FWA) or reviewing healthcare claims and utilization data.
• Experience coaching, mentoring, or providing technical guidance to junior clinical staff.
• Experience using healthcare data to identify trends and support quality improvement.
• Relevant certification or training in emergency care/triage, patient safety, quality improvement, clinical audit, or healthcare FWA.

Benefits

• Hybrid role based in Lagos, Nigeria
• Unlimited leave – take the time you need
• Premium health insurance for you and your family
• Learning and development allowance to support your growth.