Claims Risk Assessor

1 week 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.

**Role Purpose**

The Claims Risk Assessor is responsible for efficiently and effectively managing allegations related to fraud, waste, and abuse within the medical industry. This role involves receiving, analyzing, and investigating allegations, validating their credibility, and assessing the need for further action. The Assessor will also provide critical support in data retrieval for internal and external stakeholders. This position demands strong analytical and investigative skills, strict adherence to tight turnaround times, and a commitment to maintaining the quality of assessments and documentation. We are seeking individuals who are mature, hardworking, and are professional.

**Requirements**:
**Qualification**:

- Valid Matric Certificate
- Diploma or Higher Certificate in a relevant field (e.g., healthcare, law, compliance, forensics, audit, project management, investigations).

**Knowledge**:

- Previous experience in a similar role, particularly in healthcare compliance and fraud investigation.
- Strong analytical and research skills, with experience using analytical tools.
- Excellent written and verbal communication skills.
- Exceptional attention to detail and organizational abilities.
- Ability to work efficiently under pressure and meet strict deadlines.
- Understanding of healthcare regulations and fraud detection in the South African context.

**Duties & Responsibilities**

***
**Internal Process**:
Allegations Management
- Receive and document allegations related to fraud, waste, and abuse within the medical industry.
- Load allegations onto the case management system accurately and promptly.
- Ensure compliance with relevant healthcare and legal regulations.

Acknowledgment and Communication
- Send acknowledgment letters to complainants within 24 hours of receiving allegations.
- Notify relevant parties and request comments regarding the allegations.

Preliminary Investigation
- Utilize analytical tools to assess the validity of allegations.
- Review available evidence and information to make a preliminary determination.
- Determine whether a desktop investigation is needed.

Turnaround Time
- Complete the entire assessment process within a strict 7-day turnaround time.
- Manage workload and prioritize tasks to meet deadlines effectively.

Data Retrieval
- Search the case management system and relevant document repositories to provide internal and external stakeholders with requested data.
- Fulfill data requests within 5 days of receipt.

Volume Management
- Handle high volumes of allegations and data requests, adapting to fluctuations in workload.

Documentation
- Maintain detailed and accurate diary entries of all activities and assessments.
- Ensure all documentation meets high-quality standards and compliance requirements with the Administration Agreement, Client Standard Operating Procedure Documents and internal processes.

Compliance
- Adhere to all relevant healthcare, legal, and compliance policies and procedures.

**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.
- Make recommendations to improve client service and fair treatment of clients within area of responsibility.
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
- Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
- Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
- Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

**People**:

- Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
- Positively influence and manage change and offer specialist support where required.
- Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement

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