Risk Analyst X2

2 weeks ago

Bellville, Western Cape, South Africa Health Solutions Full time

Introduction

  • Through our clientfacing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members. Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.
    Role Purpose
  • Preliminary analysis and investigation of allegations related to fraud, waste, and abuse within the medical claims environment

Requirements:

Qualifications:

  • Matric
  • Bachelor's degree, diploma or higher certificate in a relevant field (e.g., healthcare, law, auditing, forensics).
  • Association of Certified Fraud Examiners (ACFE)
  • Certification in fraud examination, healthcare compliance or a related field is desirable.

Knowledge:

  • Proven experience in healthcare compliance and fraud investigation, with expertise in healthcare fraud, waste, and abuse will be advantageous.
  • Proven clinical expertise or knowledge will be advantageous.
  • Strong analytical and research skills, with experience using various analytical tools to conduct desktop investigations.
  • Excellent written and verbal communication skills.
  • Exceptional attention to detail and organisational abilities.

Experience:

  • 5 years experience in medical aids claims investigation or claims adjudication.

Duties & Responsibilities

Internal Process:

Allegations Management:

  • Oversee and facilitate the efficient receipt and documentation of allegations related to fraud, waste, and abuse.
  • Ensure accurate and prompt loading and equitable distribution of allegations onto the case management system and within the team.

Acknowledgment and Communication:

  • Supervise the timely distribution of acknowledgment letters to complainants within 24 hours of receiving allegations.
  • Manage notifications to relevant parties and request comments regarding the allegations.

Preliminary Investigation:

  • Lead the use of analytical tools to assess the credibility of allegations.
  • Ensure thorough reviews of available evidence and information, identifying more complex investigations early on and making preliminary determinations with a tighter turnaround time than Claims Risk Assessors.
  • Determine whether a fullscale investigation is warranted with a 50% tighter turnaround time.

Full Investigations:

  • Conduct full investigations for hotline complaints assessed as low risk profiles but with valid disputed claims with the turnaround time stipulated.
  • Ensure that full investigations are conducted meticulously and in compliance with all relevant policies, SOPs and regulations.

Process Improvement:

  • Facilitate and take ownership of implementing process improvements to enhance the efficiency and effectiveness of the investigative process, becoming a culture champion for positive change.

Limited Leadership:

  • Temporarily step into a limited leadership capacity when required, providing guidance and support to the team.

Client:

  • Build and maintain relationships with clients and internal and external stakeholders.
  • Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed.
  • Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
  • Interview members, healthcare providers and other parties to collect evidence regarding questionable claims.
  • Provide expert guidance and support to existing investigators on complex cases and assist in their professional development.

People:

  • Lead by example through strong work ethic, integrity and respect towards all team members and all managers. Even though this role may not have direct managerial authority, strong leadership qualities are essential.

Finance:

  • Identify solutions to enhance cost effectiveness and increase operational efficiency.
  • Implement and provide input into governance processes, systems and legislation within area of specialisation.
  • Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes.
  • Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.

Competencies

  • Time management
  • Attention to detail
  • Problemsolving
  • Communication
  • Adherence to regulations
  • Professionalism: Uphold the highest standards of ethics, integrity and confidentiality in decisionmaking and actions.
  • Expertise: Demonstrate a high level of expertis

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