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.