Senior Claims Risk Specialist X2

3 weeks ago

Bellville, South Africa Health Solutions Full time

**Introduction**
- Through our client-facing 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.**Disclaimer**
- As an applicant, please verify the legitimacy of this job advert on our company career page.**Role Purpose**
- This role involves conducting complex investigations into suspicious or fraudulent claims submitted to the medical scheme.
- Reviewing claim patterns to identify anomalies and irregularities.
- Analysing billing data and referral patterns to detect improper claims.
- Interviewing members and healthcare providers to collect evidence regarding questionable claims.
- Preparing detailed investigation reports, summarising findings and recommending corrective actions.

**Requirements**:
**Qualifications**:

- Matric or equivalent
- Bachelor’s degree in healthcare management, finance, accounting, auditing, forensics or a related field
- Advanced degree in Forensics, Compliance, Accounting, Investigations and Forensic Accounting, Commerce, Auditing or Forensic Auditing (Preferrable )
- Association of Certified Fraud Examiners (ACFE)
- Certification in fraud examination, healthcare compliance or a related field is desirable

**Knowledge**:

- Strong understanding of medical tariff codes, billing practices and reimbursement methodologies.
- Proven track record of conducting complex investigations and uncovering fraudulent activities.
- Excellent analytical skills with the ability to interpret and analyse large volumes of data.
- Exceptional attention to detail and ability to maintain accuracy in a fast-paced and high-pressure environment.
- Excellent written and verbal communication skills, with the ability to effectively communicate findings and recommendations to diverse audiences.
- Ability to work independently with mínimal supervision and manage multiple priorities effectively.

**Experience**:

- Minimum of 5 years of experience in healthcare claims processing, medical aid schemes administration or healthcare fraud investigations.

**Duties & Responsibilities**

**Internal Process**:

- Conduct thorough desktop investigations into cases of suspected fraud, waste and abuse within healthcare claims.
- Analyse and review medical records, claims data, billing statements, and other relevant documentation to identify discrepancies, irregularities or potential fraudulent activities.
- Utilise knowledge of medical aid schemes, including their policies, scheme rules and procedures, to assess the validity of claims and identify potential fraudulent behaviour.
- Collaborate with internal stakeholders, including data analysts, clinical advisors and other investigators, to gather additional information and evidence for investigations.
- Prepare detailed investigation reports summarising findings, conclusions and recommendations for further action.
- Interview members, healthcare providers and other parties to collect evidence regarding questionable claims.
- Testify as an expert witness regarding investigation findings.

**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**
- An ability to analyse and interpret large amounts of complex data
-

  • Senior Claims Risk Specialist X2

    6 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing 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,...

  • Risk Analyst X2

    6 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing 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,...

  • Claims Risk Analyst

    8 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** Through our client-facing 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,...

  • Claims Handler: Internal Dispute Resolution X2

    7 months ago

    Bellville, South Africa Santam Full time

    CAREER OPPORTUNITY Santam Legal Claims Solutions has a position available for a CLAIMS HANDLER who will be based in BELLVILLE, GLACIER BUILDING. The position requires the skills of a dynamic individual who has experience in Short Term Insurance, specifically in a Legal, Claims environment, as well as being fully competent in the third-party indemnification...

  • Claims Risk Assessor

    6 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** Through our client-facing 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,...

  • Claims Risk Assessor

    3 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing 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,...

  • Manager: Claims

    7 months ago

    Bellville, South Africa Sanlam Full time

    **What will you do?** - A great career opportunity exists in **Santam Reinsurance’s **team in Cape Town for a **Claims Manager (Inwards)**.**What will make you successful in this role?** - This role will be responsible for overseeing and managing the processing, validation and settlement of reinsurance claims received from ceding companies. This person...

  • Team Leader: Disability Claims Specialist

    7 months ago

    Bellville, South Africa Sanlam Full time

    About Sanlam Corporate- Our vision is to be the preferred partner to Corporate and Public Sector by providing an awesome client experience and comprehensive solutions that enable the financial resilience and prosperity of those entities and their employees. We tap into over 100 years of expertise to provide cost-effective Employee Benefits and Healthcare...

  • Disability Claims Specialist

    7 months ago

    Bellville, South Africa Sanlam Full time

    **Build a successful career with us** - We’re all about building strong, lasting relationships with our employees. We know that you have hopes for your future - your career, your personal development and of achieving great things. We pride ourselves in helping our employees to realise their worth. Through its five business clusters - Sanlam Fintech, Sanlam...

  • Living Benefits Claims Consultant 1

    3 months ago

    Bellville, South Africa Sanlam Full time

    **Who are we?** The Sanlam Retail Affluent business (SRA) is dedicated to empower South Africans in the middle - and upper-income segments to be financially confident, secure and prosperous. With deep client understanding and a focus on excellence in technology, client and intermediary experiences, SRA delivers financial solutions including comprehensive...

  • Insured Claims Handler: Recoveries and Liabilities

    6 months ago

    Bellville, South Africa Sanlam Full time

    **CAREER OPPORTUNITY** - Santam Specialist Claims Services has a position available for a CLAIMS HANDLER who will be based in BELLVILLE, GLACIER BUILDING.**JOB DESCRIPTION** - This position requires the skills of a dynamic individual who has experience in Short Term Insurance, specifically in a Legal, Claims environment, as well as being fully competent in...

  • Claims Handler: Internal Dispute Resolution

    7 months ago

    Bellville, South Africa Sanlam Full time

    **OPPORTUNITY** - Santam Legal Claims Solutions has a position available for a Claims Handler: IDR who will be based in Bellville, Glacier Buidling.**WHAT WILL YOU DO** - The position requires the skills of a dynamic individual who has experience in Short Term Insurance, specifically in a Legal Claims (Subrogation) environment, as well as being fully...

  • Disability Claims Consultant

    7 months ago

    Bellville, South Africa Sanlam Full time

    **Build a successful career with us** - We’re all about building strong, lasting relationships with our employees. We know that you have hopes for your future - your career, your personal development and of achieving great things. We pride ourselves in helping our employees to realise their worth. Through its four business clusters - Sanlam Life and...

  • Disability Claims Consultant

    7 months ago

    Bellville, South Africa Sanlam Full time

    **Build a successful career with us** **Overall purpose of the role** - Assessing disability claims for validity taking into account the medical/clinical information, the job requirements and the policy contract. Case managing claimants through interaction with stakeholders aimed at facilitating successful return to work. Working closely with the...

  • IT Risk Manager

    7 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing 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,...

  • Disability Claims Specialist

    6 months ago

    Bellville, South Africa Sanlam Full time

    About Sanlam Corporate Our vision is to be the preferred partner to Corporate and Public Sector by providing an awesome client experience and comprehensive solutions that enable the financial resilience and prosperity of those entities and their employees. We tap into over 100 years of expertise to provide cost-effective Employee Benefits and Healthcare...

  • First Line Manager:living Benefit Claims

    3 months ago

    Bellville, South Africa Sanlam Full time

    **Who are we?** The SA Retail Affluent cluster is responsible for Sanlam’s Retail Affluent business in South Africa. The Retail Affluent provides clients across different market segments with a comprehensive range of appropriate and competitive financial solutions. SA Retail Affluent also provides services to the wider Sanlam Group, amongst other...

  • IT Risk Officer

    3 months ago

    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing 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,...

  • Credit Risk Specialist

    22 hours ago

    Bellville, Western Cape, South Africa Frogg Recruitment SA Full time

    Become a key player in the mortgage industry as a Credit Risk Specialist at Frogg Recruitment SA.We are seeking an experienced professional to manage our home loans portfolio, ensuring creditworthiness and affordability procedures are performed accurately.The ideal candidate will have:1-2 years experience in credit analysis or a related fieldDemonstrated...

  • First Line Manager: Living Benefit Claims

    4 months ago

    Bellville, South Africa Sanlam Full time

    **Who are we?** The SA Retail Affluent cluster is responsible for Sanlam’s Retail Affluent business in South Africa. The Retail Affluent provides clients across different market segments with a comprehensive range of appropriate and competitive financial solutions. SA Retail Affluent also provides services to the wider Sanlam Group, amongst others...