Closed File Review Officer

Job Objective/ Purpose of Job:

Responsible for post-payment reviews of claims to identify anomalies, errors, or fraudulent activities that may have bypassed initial scrutiny. The officer will ensure compliance, recover undue payments, and recommend process improvements.

Responsibility:

• Retrospective Audits & Investigations
• Provider Engagement & Escalation
• Data Analysis & Reporting
• Team Oversight & Capacity Building
• Frameworks & Strategic Contribution

Education/ Professional Qualification:

• MBBS Degree from a reputable Tertiary Institution.
• Data Analytics knowledge/ qualification.

Experience:

• Clinical or Claims Review Skills: Ability to understand medical case notes, diagnoses, procedures, and provider billing.
• Attention to Detail: Meticulous record-checking and cross-referencing of documents.
• Health Sector Experience: Prior work with HMOs, hospitals, claims teams, or provider audits.
• Documentation Skills: Capable of writing clear, evidence-backed summaries and audit findings.
• Collaborative Mindset: Works with FWA officers, nurses, and field auditors.
• Basic Data Interpretation: Able to read trends, flags, and simple analytics from claims data.
• Product knowledge
• Medical network knowledge
• Medical knowledge
• Legal knowledge
• IT systems
• Analytical reasoning
• Project management