Clinical Fraud Risk Specialist

2 weeks ago

Pretoria, Gauteng, South Africa Discovery Limited Full time
Select how often (in days) to receive an alert:

Clinical Fraud Risk Specialist Business Unit:
Discovery Health

Function:
Clinical

Date: 27 May 2024
Discovery Health
Clinical Fraud Risk Specialist Job level – Associate Specialist level
About Discovery Discovery's core purpose is to make people healthier and to enhance and protect their lives.

We seek out and invest in exceptional individuals who understand and support our core purpose, and whose own values align with those of Discovery.

Our fast-paced and dynamic environment enables smart, self-driven people to be their best.

As global thought leaders, Discovery is passionate about innovating in order to not only achieve financial success, but to ignite positive and meaningful change within our society.

Key Purpose To identify and manage potential fraud and abuse for all schemes under administration within the health business.

Areas of responsibility may include but are not limited to: To identify and prevent scheme exposure to fraud, waste and abuse related to inappropriate or erroneous claims submitted by healthcare providers.

To analyse and audit claims for clinical appropriateness, adherence to billing guidelines and potential areas of abuse.

Analyse provider, member, and facility spike/outlier reports/data to identify any fraudulent trends and once identified, provide full insight into all aspects of the case including the how, why, and when the potential fraud/abuse was committed.

Support and work closely with the forensic investigations team regarding clinical coding and clinical audits on healthcare professionals. NHRPL coding support i.e.

Provide clinical and coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review and analytics.

Recommend risk mitigation strategies and/or reports for tracking activities to proactively curb waste and abuse. Where necessary, engage with professional societies to obtain opinion on trends identified. Manage the workload to ensure that cases/reports are handled appropriately and resolved in a timely manner. Provide prompt & accurate feedback to all parties involved in an investigation or area of concern.

Be able to compile presentations and risk reports for Schemes as and when necessary Personal Attributes and Skills Expresses opinions, information, and key points of an argument clearly.

Monitors performance against deadlines and milestones. Sets high standards for quality and quantity. Makes rational judgments from the available information and analysis. Takes initiative and works under own direction - self-starter. Focuses on customer needs. Upholds ethics and values; demonstrates integrity. Be flexible in handling multiple projects and audits simultaneously. Communicates clearly and effectively. Education and Experience Clinical Degree NHRPL coding knowledge across all/any practice types. ICD-10 coding knowledge. Understanding of PMB benefits and regulations.

Knowledge of Discovery Health products Microsoft literacy essential:
Excel, Word and Power point Discovery systems (e.g. Claims; DCS etc.)

Advantageous requirements:
Any additional auditing, fraud or data analytics experience or certifications will be advantageous. EMPLOYMENT EQUITY

The Company's approved Employment Equity Plan and Targets will be considered as part of the recruitment process. As an Equal Opportunities employer, we actively encourage and welcome people with various disabilities to apply.
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