Claims Risk Analyst
9 hours ago
-Introduction
Momentum Health Solutions, an entity of Momentum Metropolitan Holdings Limited delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation, and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
Role Purpose
An opportunity exists for a dynamic, focused individual to be part of the forensic investigations team in the Health Investigations Unit (HIU) to perform complex investigations into allegations of fraud, waste and abuse within the medical aid industry; and perform a supervisory role within the Investigations Teams.
Requirements
- Matric certificate
- Tertiary qualification in Law, Compliance, Accounting or Forensic Auditing
- At least 3 years forensic or investigative experience
- An ability to analyse and interpret large amounts of complex data
- Able to work productively remotely with strong time-management skills
- Proven and exceptional organising and co-ordinating skills
- Must be able to travel on behalf of the office when required
- Medical Industry knowledge (Advantageous)
- Familiarity with Oracle, Cubes or FAMS operating systems (Advantageous)
Duties & Responsibilities
- Using data analysis techniques to detect potential fraud, waste and abuse
- Performing investigations into allegations of fraud, waste and abuse
- Engaging scheme members, healthcare service providers and other third parties
- Using data visualization software to enhance investigations
- Continuous development of your own professional knowledge of the medical schemes environment and forensics discipline
- Compiling comprehensive case reports
- Liaising with Societies, Regulators and Clinical Specialists
- Reporting cases to the relevant Regulatory Bodies or to SAPS
- Liaison person between the Operations, Systems and Investigations teams
- Performing a supervisory role within the team
- Providing support to the management team to ensure that client Service Level Agreements (SLA's) are adhered to
- Communicating with respective service provider network companies
- Compiling weekly client reports
- Co-ordinating and implementing approved sanctions
- Contributing to a culture of teamwork and innovative thinking
- Presenting cases / findings to clients
Competencies
- Proficient in MS Office (particularly Excel and Word)
- Excellent written and verbal communication skills
- Strong report writing skills
- Attention to detail
- Leadership and peer mentorship ability
- Strong personal integrity
- Able to work well under pressure
- Adaptability
- Strong work ethic
- Passion for health investigations
- Commitment to the collective success of the unit
- Client
- centricity
- Self-motivated and driven
Policy
We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.
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