Case Managers (Freelance) at Reliance HMO

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

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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