Closed File Review Officer - Lagos at AXA Mansard

JOB DESCRIPTION AND EXPECTATIONS

• 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

Academic/Professional: MBBS Degree from a reputable Tertiary Institution. Data Analytics knowledge/ qualification will be an added advantage.

Work experience: 1 -4 Years’ Experience in Claims related.

Job Level: This position has been profiled as a minimum Analyst role owing to the defined skill level, years of experience and complexities of the task to be performed.

Grade Level: This position has been profiled as a minimum Grade Level 9 owing to the defined skill level, years of experience and complexities of the task to be performed.

Key Responsibilities

• Review closed claims for medical fraud, billing anomalies, and coding errors.
• Identify patterns such as excessive billing, duplicate submissions, or unauthorized charges.
• Collaborate with claims, fraud, and recovery teams to validate findings and assess recovery actions.
• Engage with healthcare providers during audits, closeout discussions, and recovery negotiations.
• Represent the audit team in provider-related escalations and ensure due process is followed.
• Liaise with internal departments such as Claims, Healthcare Services, Provider Relations, Operational Risk, and Internal Control.
• Analyse claims data to detect emerging fraud patterns and trends.
• Recommend proactive measures and prevention strategies to reduce fraud exposure.
• Track and report audit recoveries using relevant platforms and systems.
• Contribute to the development and refinement of FWA SOPs, red flag documents, and audit workflows.
• Review and validate audit reports for accuracy, clarity, and actionable recommendations.
• Lead or support initiatives like the creation of an audit glossary, operational guide, or resource hub.
• Supervise daily activities of the Audit Team, ensuring audit targets and timelines are met.
• Conduct all other duties that will be assigned from time to time by the Line Manager(s) from time to time.